Blog and Helpful Articles

What We’re Reading – Bilateral procedures and MUEs

Are you stumped on when to use modifier 50 instead of modifiers LT and/or RT for Medicare? Modifier 50 is defined as a bilateral procedure which is performed on both sides of the body in the same operative session or on the same day.  If, however, the description of the CPT (Current Procedural Terminology) code specifies that the code is for a unilateral and/or bilateral procedure, modifier 50 would not be appropriate. Unilateral injections are performed on one side of the joint, while bilateral injections are performed on the right and left side of the joint. For example, for CPT code 64479, you would use modifier LT or RT if the procedure was only performed on one side.  If injection was on both sides of the joint, you would use modifier 50.

The First Coast Service Options website provides a great resource to help you determine if modifier 50 should be used: the Medicare Physician Fee Schedule (MPFS) look-up tool under the indicator “bilateral surgery.” To find out more details refer back to First Coast Service Options billing news.  Remember also that not all payors use Medicare’s guidelines so check with each one to understand its billing rules for these modifiers.

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What We’re Reading – Manual update regarding the repayment of overpayments

If your business has ever received a demand letter from Medicare regarding overpayments, your first thought has probably been, “How am I going to pay this back while keeping my business afloat?”  There is good news!  Effective September 3, 2013, an update to chapter 4 of the CMS manual Medicare Financial Management may ease some of your worries.  A provider has the option of submitting an Extended Repayment Schedule (ERS) request, formerly named Extended Repayment Plan (ERP), if repayment within a 30 day period would represent a “hardship.”  If the request is approved, it can result in anywhere from a six- to a 36- month extension to the Medicare contractor and/or up to 60 months with the Centers for Medicare & Medicaid (CMS).  Between the shaky economy and redoubled scrutiny of Recovery Audit Contractors, this may be a lifesaver for providers and give them some breathing room if they’re targeted for overpayments.  To find out more details refer back to First Coast Service Options billing news.

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Professional Association involvement: It’s not just for “newbies”

Students and early careerists often ask about the most important contributor to career success.  The answer never lends itself to just one factor, but usually to a list of the top three, which includes professional organization involvement.  In addition, this involvement can be generalized to an individual of any professional level and at any career stage.  One’s definition of success hardly matters either, as professional organizations can be instrumental to a host of “success markers,” such as income, influence, and personal enrichment.

Selecting the right professional association is a key step; I am partial to the American College of Healthcare Executives (ACHE) for its strength and breadth within the healthcare realm.  In addition to that, involvement in organizations that focus on specific niches within the profession is a good idea; among the most well-known are the Healthcare Financial Management Association (HFMA), Medical Group Management Association (MGMA) and the Health Information Management and Systems Society (HIMSS).  These are national in scope but local chapters serve as community hubs for membership development.

The first benefit of professional organizations is the vital link to relevant continuing education, something we all need to excel in our careers and ensure we can lead our organizations successfully into the future.  The rapidly changing nature of our profession, coupled with its prominence in the national spotlight, makes current information about trends paramount to serving the needs of all constituents.  Journal reading can certainly keep us current but if you’re like me, a few publications sit on your desk, still wrapped in plastic.

Aside from the obvious educational advantages are the personal ones, and here is where the right mindset is crucial to professional organization involvement.  Over the years, I’ve observed a few common types of professionals:

  • Those who are only visible when they need something (e.g., a job, or specific contact in order to get a job): these professionals seek only to use their contacts when it suits them, a fact that isn’t lost on their network.  Once they’ve obtained what they need, they vanish.
  • People who are “too busy” to become involved, or believe they’re “all set,” career-wise, and thus don’t need the professional involvement: they rob themselves of being known by others and of the gratification of benefiting an early careerist or a professional in transition.  It’s safe to say that none of us arrived at success without encouragement or assistance from others.  “Paying it forward” is one way we honor those who helped along the way and extend their influence to others.
  • Individuals who realize the immense benefit of cultivating contacts for the value of the relationships themselves: they get to know others in the profession for the enjoyment of it.  Often these relationships are beneficial to our careers, but that’s a bonus to connections that are intrinsically satisfying.  When faced with an individual who is in professional limbo, these people don’t feel pressured to “find someone a job;” they can encourage, advise, and/or offer other assistance which may include introductions to people in their own networks.

The pace of business these days seduces us to restrict our circles.  Work, after-hours meetings, children’s soccer games, friends, neighbors and aging parents can form an endless list of demands that seems to preclude professional involvement.  My suggestion is to pick one organization and start with quarterly attendance at professional events.  Consider inviting a colleague to attend with you.  Schedule events ahead of time and block the time in your calendar so that only a true emergency forces you to cancel.

If the prospect of speaking to “strangers” gives you pause, re-frame the thought and dub them “friends in waiting.”  Look for someone to encourage.  Before you know it,  you’ll have enjoyed learning about a current topic, and begun planting a network of seeds you can water in the coming months.

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What We’re Reading – Preventing duplicate claim denials

Are you experiencing more claims denials as duplicates recently?  Make sure that your billing staff and/or billing company are aware that effective July 1, 2013, The Centers for Medicare & Medicaid Services (CMS) instituted new claim edits.  All claims received are now reviewed against any and all “paid, finalized, pending and same claim details,” looking for any duplication submitted without the appropriate modifiers.

This article gives a few examples of those modifiers and when to use them.  Save yourself time and money in the long run by reviewing your claims to make sure they’re not being denied for this reason.

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Differences & Similarities between Home Health Agencies and Nurse Registries – Part 3

Welcome to the third part of our series about the differences between home health agencies and nurse registries. In this installment, we’ll review the last criterion from our list:  one qualifying service by direct employee.

Medicare requires that a home health agency provide skilled nursing services and at least one other therapeutic service (physical, speech or occupational therapy; medical social services; or home health aide services) by direct employee. For example, if the agency selects physical therapy services as the “direct employee service”, all physical therapy care delivered by the agency must be by an employee and not by an independent contractor or anyone outside organization. Conversely, that would require that the agency has no physical therapists who are independent contractors with the agency. After satisfying that Medicare Condition of Participation, (MCOP), a home health agency may engage independent contractors to provide all other services.

Regarding independent contractors, one should be aware of the very fine line between the factors which determine whether an individual is, in fact, an independent contractor.   The Department of Labor and IRS have regulations regarding the classification of individuals, and a quick internet search will provide the Medicare Certified home health agency with an often used “20 Factor Checklist” of issues to help determine whether one would be classified as an independent contractor or an employee.

The MCOP has strict requirements of home health agencies regarding supervision and responsibility for care provided by persons under contract. Accrediting organizations require even more in-depth involvement with supervision of contractors. The State of Florida does not require the extent of supervision of contractors as the MCOP and accrediting organizations do.

Nurse registries, on the other hand, must provide all direct patient care services through independent contractors and are prohibited from providing direct patient care services by employee in accordance with Florida law.  They may provide only skilled nursing, home health aide services, (by home health aides or certified nursing assistants), or homemaker and companion services. Nurse registries are not licensed to provide therapy services.

This concludes our three-part series on the differences between home health agencies and nurse registries. As you may know, there are many other distinctions, but we’ve presented our “top three.”

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Differences & Similarities between Home Health Agencies and Nurse Registries – Part 2

We’ve been exploring the differences between home health agencies and nurse registries in this three-part series.  In the first installment, we looked at the issues of billing Medicare and Medicaid.  In this part, we’ll cover the second difference: responsibility for a patient’s health.

Medicare Conditions of Participation require that the home health agency only accept a patient for treatment based “on a reasonable expectation that the patient’s medical, nursing, and social needs can be met adequately by the agency…” Also, an agency is required to, in addition to other requirements: maintain a robust quality assurance program designed to ensure that all standard health care practices are implemented and observed; maintain a group of professional personnel, which must include a physician and a registered nurse, who will meet to review and advise on the agency’s provision of services; and assure that  the provision of care is prescribed and supervised by a physician, including regular communication and collaboration with all care providers regarding the patient’s condition and services provided.

A nurse registry is not required – or allowed – to become as intricately involved in a patient’s care and to dictate the manner in which that care is provided.  Nurse registries do not employ direct care providers; they contract with independent staff to deliver the care and service needed by the registry’s patients.  The registry’s role is to secure licensed, capable direct care providers, who carry out the services in accordance with the professional standards of their profession, whether medical or quasi-medical. In addition, the registry is required to advise the patient that all care and services will be provided by an independent contractor.

This concludes the second part of our series about the differences between home health agencies and nurse registries.  In part three, we will review the last major distinction:  that of the qualifying service.  Join us next time!

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Differences & Similarities between Home Health Agencies and Nurse Registries – Part 1

Many individuals who consider entering the market as a home health provider in Florida come to us with the same questions: What is the difference between a home health agency and a nurse registry? What factors should I consider when deciding which license to pursue? This series will highlight – in no particular order – what we believe to be the major differences, and similarities, between home health agencies and nurse registries.

1. Billing Medicare & Medicaid.

It is difficult to list in order of priority the differences between these two license types. However, it would seem that a home health agency’s ability to bill Medicare/Medicaid would stand out, not only because of the revenue source, but because of the other factors such enrollment requires, such as the mandatory accreditation, responsibility for a patient’s health and that at least one qualifying service be provided by a direct employee. 

To become enrolled as a Medicare home health provider an organization must be accredited by one of three nationally recognized organizations. The Accreditation Commission for Health Care, the Community Health Accreditation Program and The Joint Commission have been granted “deeming authority” by the Centers for Medicare and Medicaid Services. This authority allows these three organizations to determine whether, or deem that, a home health agency meets the strict requirements to participate in Medicare, as well as each organization’s particular ‘standards’ for operation. Further, in 2008, Florida began the requirement that an organization must be accredited prior to the issuance of a home health agency license. Not all home health agencies in Florida choose to become a Medicare enrolled provider or to provide skilled care. However, to obtain a home health license, whether providing skilled care or whether intending to become Medicare certified, or not, accreditation must be obtained.

A nurse registry cannot bill Medicare or Medicaid, with the exception of billing for participation in Medicaid Waiver programs. The main factor of revenue source serves to differentiate, to a large degree, a home health agency from a nurse registry.

In our next installment in this series, we’ll look at the second distinction between home health agencies and nurse registries: Responsibility for the patient’s health.

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What We’re Reading – Boost Reimbursement through Improved Documentation: 5 Tips

Physicians and coders/billers need to be on the same page when it comes to getting claims processed and reimbursed correctly.  The key to this – and you’re probably sick of hearing it – is documentation.  Especially with ICD-10 coming around the corner, documentation is key and must be precise.  This article offers great tips on improving documentation; here are a few:

  • Do avoid EHR (Electronic Health Record) shortcuts –physicians’ time is valuable and with the use of EHRs, the ability to cut and paste and/or use a template for progress notes can be viewed as a timesaver.  Keep in mind, though, that a patient’s progress note is a vital document in correct reimbursement, especially if the payor asks for supporting documents.   If something is missing on unclear, due to poor charting, the payor might have a hard time determining the medical necessity for that service.
  • Do be exact when time is a factor – If a specific CPT (Current Procedural Terminology) code calls for a timeframe, the accurate time spent and what exactly was reviewed must be documented on the patient’s progress note.
  • Do give procedure specifics – If an injection is given in both knees – for example – be sure to have supporting documentation that the procedure was bilateral as well as the medication and dosage.  Or if patient has lesions, the measurements must be documented in addition to a notation of whether the margins were included or not.  Finally, any difficulties or complications that arose from a procedure need documentation about the physician’s determination.
  • Do provide full diagnosis detail – The coder can only code to the highest level of specificity with the documentation provided.  Be as precise as you can with a patient’s condition and/or complications – for example, if the condition is mild or severe, acute or chronic, diastolic or systolic, etc.  This will be a crucial element in ICD-10 coding because the use of the unspecified codes will slowly decrease.  Practice proper and specific documentation now so that when the coding change happens, the coder will be able to translate the documentation to the correct diagnosis code.
  • Do document E&M elements in full – For each patient visit make sure to meet or surpass the documentation guidelines for the three components in the E&M level: history, examination and medical decision-making process.  A frequent issue is under-documenting the Review of Systems (ROS) in the examination.

The common thread throughout this whole article is how vital proper documentation is and its importance in proper claims payment.

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Maximizing the first patient visit of a period

Risk adjusted reimbursement hinges on proper management and reporting of a patient’s chronic conditions.  We always advise clients to assess all chronic conditions at least twice per year: once in the period between January 1st and June 30th and again between July 1st and December 31st.    We often review a patient’s chart and see that the first visit of the year was for an urgent condition, which the physician treated; the provider also noted that he or she would complete an exam on the next visit.  Too often, patients fail to keep those follow up appointments.  In addition, the appointments sometimes occur long after the initial urgent visit.

Why is this an issue?  First of all, chronic conditions require regular management to prevent acute events. Acute events are expensive (in terms of medical costs and in their toll on the patient’s health), and a schedule of regular visits will minimize emergency department visits and hospital admissions.  In addition, from a risk adjusted reimbursement standpoint, the provider (or the group or plan) incurs expenses in the regular management of chronic conditions.  They range from medication expenses to specialty consults.  Without a PCP’s assessment, documentation and coding of those conditions – many of which fall under the CMS-HCC model – the funding may be incorrect or inadequate to cover the cost of the care the patient has received. Moreover, if the patient should die prior to that follow-up appointment, the opportunity to report those conditions is permanently lost and the funding for the period will be incorrect.

We urge all clients to develop a campaign to bring all patients in at least twice per year and to make sure patients receive a thorough health risk assessment.  Not only is this good for the patient, but it’s vital for the practice. Finally, review the documentation and coding to ensure all the conditions are properly substantiated.  This will result in proper payments and minimize the likelihood of retroactive funding adjustments.

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What We’re Reading – How Practice Managers Can Alleviate Physician Stress

Stress has become a common factor in every household and business and we all need someone or something to lighten our loads so the weight of the world isn’t resting on our shoulders. This article focuses on physicians and how the support staff and the practice manager can ease their stress levels.  The myriad incentives, programs and guidelines cause great concern and stress among physicians who strive to continue providing quality patient care amidst multiple demands.  Perhaps this author’s ideas will reduce the stress for the physician as well as the entire staff.

  • Don’t wait – As soon as you see changes in your providers, pull them aside and talk it out.  Ask, “What can I do to lighten your load?”  Together, you can work out a plan that will benefit everyone.
  • Walk the talk – Let your staff know that their health and welfare are a top concern.  Check in with them often to see if there is anything you can do to streamline processes and keep things running smoothly.
  • Work smarter – Make sure the work schedule is realistic for your docs, that they have enough time to spend with each patient.  Of course, we need to balance that with making sure they aren’t constantly running behind for the next appointment.  Perhaps your front staff can remind patients how vital it is for them to be on time for appointments.
  • Take time for yourself – It’s important to balance work with down-time, so throughout the day, don’t forget to schedule “you time.” Whether it’s a walk around the block, catching up on leisure reading, hitting the gym during lunch, do whatever will give you that joy to finish up the day.

There’s an old saying, “A happy wife is a happy life.” The same thing can be said about an organization.

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