Wisconsin Medical Journal
107 #7
107 #7
Mastering Medicare in 2008–Follow-up Questions
Are decimal points allowed in the fields for reporting hematocrit and hemoglobin?
Can Clinical Social Worker bill Medicare for smoking cessation codes 99406 & 99407?
Is the correct code for the administration of the Hepatitis B vaccine, G0010?
The codes that we are questioning are 90760 and 90774. We occasionally have patient's that will come in for a migraine and they have vomiting and dehydration stemming from the migraine. The provider will give them IV fluids for their dehydration (between 30-60 min's) and then in the meantime will push an IV med. CPT states both 90760 and 90774 are initial codes only. How would we code this?
Should critical access hospitals be billing Medicare Part D for Zostavax and other non-Part B covered vaccinations?
Can you bill chemotherapy infusion and 90772 for the push of another substance (different location) on the same day with a 59 modifier?
Please post a copy of the most current E/M audit sheet.
Can you provide evidence of the actual date of service and place of service information? For example, reading radiology tests, etc.
Do you need the mammography certification number on claims for the professional component only?
If you accept assignment and two years after claims were paid you find out that the patient actually had Medicare primary, is there anyway to get these paid past timely filing?
What is the N&E of assignment?
Can freestanding critical access facilities report PQRI for their physician claims that are filed to Part B?
Can you append a 50 modifier to an ASC facility charge?
Can you provide additional information on the collapsing of PTAN’s?
Is there a reason currently why modifier 76 as opposed to 91 would be required on repeat lab services? (Genetic testing)
Can you provide information on the reporting of both a peripheral and axial bone density study on the same day?
What is required as documentation for reporting a level of consultation or E/M based on time? Do you need to document the total time counseling and the total time of the visit (ex: 35 of 45 minutes spent counseling)?
The following questions are on the use of the AQ modifier as it relates to HPSA’s.
The main question I have is regarding reading radiology services after hours from one hospital location for a couple other local hospitals. These are all in the same billing locality. Our radiologists are at one main location here in Green Bay from 5pm until 7am every day. During these hours, they will talk with the techs at the other locations, review progress of images with them and interpret the studies performed on that hospital's equipment. These are either ER dept patients or in-patients. Are we supposed to use the hospital they are physically located at as the POS? If so, it seems odd that we would bill out an "in-patient" charge for one hospital (where the radiologist is located) and the patient is an in-patient at another hospital. The studies won't match up to the patient's hospital stay.
If the patient is seen in the ER and the ER doctor orders a CT scan and they are brought back to the radiology dept for the CT , should we be billing the POS as ER or outpatient? I realize that Medicare doesn't reimburse differently for ER versus outpatient/inpatient, but many of the other insurance carriers want the POS to be the ER in these situations, because their coverage can be different if the treatment was of an emergent nature.
If x-ray films are performed at a clinic across the street from the hospital and brought to the hospital for our radiologists to read, do we use the clinic info (POS 11 for office) or do we use the hospital location (POS 22-outpatient) even though the patient never stepped foot in the hospital?
At the seminar I was told that we could not bill Part B for the Zostavax vaccine, in fact I was told it may be considered abuse. Please advise on correct or acceptable billing for zostavax.
For the most part, our radiologists perform interpretations in their offices - but since the films are all electronic, they can do the interpretations anywhere they have a computer. Occasionally, they will be in the hospital and will sit down at a computer, bring up films and do interpretationss from there. Do we have to have to bill these out with place of service hospital? If so, inpatient or outpatient? How do we know in the billing office, when the doc reads a film at the hospital?
Somewhat related, a few years ago, our organization was instructed that our radiology exams had to state where the exam was interpreted. For example: the bottom of the report would say: "This exam is interpreted at the XXXXX Clinic". Is this really necessary?
Are decimal points allowed in the fields for reporting hematocrit and hemoglobin?
Yes
Can Clinical Social Worker bill Medicare for smoking cessation codes 99406 & 99407?
No
Is the correct code for the administration of the Hepatitis B vaccine, G0010?
Yes, for 2008, the HCPCS book verifies this.
The codes that we are questioning are 90760 and 90774. We occasionally have patient's that will come in for a migraine and they have vomiting and dehydration stemming from the migraine. The provider will give them IV fluids for their dehydration (between 30-60 min's) and then in the meantime will push an IV med. CPT states both 90760 and 90774 are initial codes only. How would we code this?
90774 & 90761 According to the CPT Professional Edition, 90761 is reported to identify hydration if provided as a secondary or subsequent service after a different initial service (90760, 90774, 96409, 96413) is administered through the same IV access. The RVU’s for these services should not be used to determine the order.
Should critical access hospitals be billing Medicare Part D for Zostavax and other non-Part B covered vaccinations?
This is a Part D covered benefit and if the patient has Part D it should be billed to Part D. Contact Part D plans for additional information.
Can you bill chemotherapy infusion and 90772 for the push of another substance (different location) on the same day with a 59 modifier?
Yes, assuring documentation supports the separate sites of service.
Please post a copy of the most current E/M audit sheet.
WPS does not use an audit sheet. The Wisconsin Medical Society does not endorse any one specific audit sheet, but samples can be found here: inpatient or outpatient.
Can you provide evidence of the actual date of service and place of service information? For example, reading radiology tests, etc.
A general rule is to bill the service where the provider actually performed the service and on the day the provider performed the service. There are some exceptions. See scenarios in other Questions and Answers.
Do you need the mammography certification number on claims for the professional component only?
No
If you accept assignment and two years after claims were paid you find out that the patient actually had Medicare primary, is there anyway to get these paid past timely filing?
No
What is the N&E of assignment?
The Nature and Effect of Assignment explains that Assignment is a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to let the physician or other supplier request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. The physician/supplier in return agrees to accept the Medicare allowed payment amount by the carrier as his/her full charge for the items or services. A physician/supplier who agrees to accept assignment on all claims for Medicare services, rather than on a claim-by-claim basis is known as a participating physician/supplier. See Publication 100-4, chapter 1, sections 30.3 and 30.3.12.2 of the IOM. In effect, the physician/supplier who accepts assignment on a claim-by-claim basis or who is a participating physician/supplier is precluded from charging the enrollee more than the deductible and coinsurance based upon the approved payment amount determination. If dissatisfied with the amount of the Medicare allowed amount, a physician/supplier may follow the procedures for appeals of contractor initial determinations. You can read more in Publication 100-4, Chapter 1, Section 30.3.2 found at http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.
The following section speaks to what the beneficiary owes on a claim that cannot be paid due to untimely filing:
Excerpted from Publication 100-4, Chapter 1, Section 70.4 70.4 - Determination of Untimely Filing and Resulting Actions (Rev. 830, Issued: 02-02-06, Effective: 07-01-06, Implementation: 07-03-06)
Medicare denies a claim that is not filed timely as specified in §70.1. Medicare determines whether a claim has been filed timely by comparing the date the services were furnished (line item date or claim statement “from” date) to the receipt date applied to the claim when it is received. If the span between these two dates exceeds the time limitation specified in §70.1, the claim is considered to have been not timely filed. When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal. Where the beneficiary request for payment was filed timely (or would have been filed the request timely had the provider taken action to obtain a request from the patient whom the provider knew or had reason to believe might be a beneficiary) but the provider is responsible for not filing a timely claim, the provider may not charge the beneficiary for the services except for such deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made.
Can freestanding critical access facilities report PQRI for their physician claims that are filed to Part B?
PQRI codes may be reported for any bill that is submitted and processed under a physician’s number.
Can you append a 50 modifier to an ASC facility charge?
Modifier 50 should be appended on the professional surgical charges for ASC services.
Can you provide additional information on the collapsing of PTAN’s?
http://www.cms.hhs.gov/Transmittals/Downloads/R244PI.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5906.pdf
Is there a reason currently why modifier 76 as opposed to 91 would be required on repeat lab services? (Genetic testing)
Modifier 91 is used for Repeat Clinical Diagnostic Laboratory Testing, not for genetic testing.
Can you provide information on the reporting of both a peripheral and axial bone density study on the same day?
Refer to policy, http://www.wpsmedicare.com/part_b/policy/ms004.pdf>
“There are limited clinical situations, where it may be appropriate to do both axial and peripheral bone mineral density (BMD) studies on the same date of service, or within thirty days of each other. Medicare will not reimburse for both axial and appendicular testing on the same date of service or within thirty days of each other, unless the medical records substantiate that the patient has artificial instrumentation in place in either hip or spine, or other conditions that precludes a reading in those locations. These other conditions may include the following;
What is required as documentation for reporting a level of consultation or E/M based on time? Do you need to document the total time counseling and the total time of the visit (ex: 35 of 45 minutes spent counseling)?
Both Transmittal 788 and the CMS 95 and 97 Documentation Guidelines state “If the level of service is reported based on counseling and/or coordination of care, the total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care.”
The statement in CMS Publication 100-04, Chapter 12, Section 30.6.1.C states "the duration of the counseling/coordination of care that is provided face-to-face or on the floor may be estimated, but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of services that involves predominantly coordination of care or counseling.”
The following CPT Assistant articles also discuss documentation of time and indicate the total visit time, total counseling time and summary of the counseling be documented: October 2003 and August 2004.
The best practices method of recording time would be to include the time spent counseling, the total time of the encounter and the details of the counseling and coordination of care provided.
The following questions are on the use of the AQ modifier as it relates to HPSA’s.
Medicare reimbursement is 5% higher for providers that participate versus those that do not participate. The following links contain information on participating, non-participating and opting out of Medicare.
http://www.wpsmedicare.com/part_b/business/med_participation.shtml
http://www.wpsmedicare.com/part_b/business/enroll_opt.shtml
The main question I have is regarding reading radiology services after hours from one hospital location for a couple other local hospitals. These are all in the same billing locality. Our radiologists are at one main location here in Green Bay from 5pm until 7am every day. During these hours, they will talk with the techs at the other locations, review progress of images with them and interpret the studies performed on that hospital's equipment. These are either ER dept patients or in-patients. Are we supposed to use the hospital they are physically located at as the POS? If so, it seems odd that we would bill out an "in-patient" charge for one hospital (where the radiologist is located) and the patient is an in-patient at another hospital. The studies won't match up to the patient's hospital stay.
For the situation you described, you should follow the classification of the patient since a facility is involved, Therefore, if the patient is inpatient -21, outpatient - 22 or Emergency Room - 23. Medicare guidelines state you should report the address and zip code of the physical location of where the radiologist is performing services on the claim form.
If the patient is seen in the ER and the ER doctor orders a CT scan and they are brought back to the radiology dept for the CT , should we be billing the POS as ER or outpatient? I realize that Medicare doesn't reimburse differently for ER versus outpatient/inpatient, but many of the other insurance carriers want the POS to be the ER in these situations, because their coverage can be different if the treatment was of an emergent nature.
Once again, you should follow the classification of the patient since a facility is involved. For this situation, you should bill POS ER - 23. Medicare guidelines state you should report the address and zip code of the physical location of where the radiologist is performing services on the claim form.
If x-ray films are performed at a clinic across the street from the hospital and brought to the hospital for our radiologists to read, do we use the clinic info (POS 11 for office) or do we use the hospital location (POS 22-outpatient) even though the patient never stepped foot in the hospital?
This patient is not a facility patient. Report the POS to indicate the place where he radiologist is reading the x-ray film. Medicare guidelines state that you should report the address and zip code for the physical location of place where the radiologist performed his/her service.
At the seminar I was told that we could not bill Part B for the Zostavax vaccine, in fact I was told it may be considered abuse. Please advise on correct or acceptable billing for zostavax.
Since Zostavax is not covered by Medicare Part B, it is not necessary to submit a claim, nor should the provider routinely submit a claim to Medicare Part B for this service. Only in those infrequent situations such as the beneficiary does not have Medicare Part D, should a claim for Zostavax be submitted to Medicare Part B.
For the most part, our radiologists perform interpretations in their offices - but since the films are all electronic, they can do the interpretations anywhere they have a computer. Occasionally, they will be in the hospital and will sit down at a computer, bring up films and do interpretationss from there. Do we have to have to bill these out with place of service hospital? If so, inpatient or outpatient? How do we know in the billing office, when the doc reads a film at the hospital?
The physician should bill using the physical location and zip code of where they perform the services. This corresponds to the Box 32 information. As far as place of service, if the patient is an inpatient, then they should use POS 21. If the patient is not and they are in the outpatient department, they can use POS 22.
Somewhat related, a few years ago, our organization was instructed that our radiology exams had to state where the exam was interpreted. For example: the bottom of the report would say: "This exam is interpreted at the XXXXX Clinic". Is this really necessary?
WPS Medicare is not aware that this is a current requirement.
Can Clinical Social Worker bill Medicare for smoking cessation codes 99406 & 99407?
Is the correct code for the administration of the Hepatitis B vaccine, G0010?
The codes that we are questioning are 90760 and 90774. We occasionally have patient's that will come in for a migraine and they have vomiting and dehydration stemming from the migraine. The provider will give them IV fluids for their dehydration (between 30-60 min's) and then in the meantime will push an IV med. CPT states both 90760 and 90774 are initial codes only. How would we code this?
Should critical access hospitals be billing Medicare Part D for Zostavax and other non-Part B covered vaccinations?
Can you bill chemotherapy infusion and 90772 for the push of another substance (different location) on the same day with a 59 modifier?
Please post a copy of the most current E/M audit sheet.
Can you provide evidence of the actual date of service and place of service information? For example, reading radiology tests, etc.
Do you need the mammography certification number on claims for the professional component only?
If you accept assignment and two years after claims were paid you find out that the patient actually had Medicare primary, is there anyway to get these paid past timely filing?
What is the N&E of assignment?
Can freestanding critical access facilities report PQRI for their physician claims that are filed to Part B?
Can you append a 50 modifier to an ASC facility charge?
Can you provide additional information on the collapsing of PTAN’s?
Is there a reason currently why modifier 76 as opposed to 91 would be required on repeat lab services? (Genetic testing)
Can you provide information on the reporting of both a peripheral and axial bone density study on the same day?
What is required as documentation for reporting a level of consultation or E/M based on time? Do you need to document the total time counseling and the total time of the visit (ex: 35 of 45 minutes spent counseling)?
The following questions are on the use of the AQ modifier as it relates to HPSA’s.
- It is my understanding that the incentive (higher payment) is based on the provider's location by zip code. Is this correct?
- Are there specific codes that are eligible to have the AQ? Does the CMS website indicate those codes that are eligible to have the AQ modifier. OR, could the RVU indicator determine reimbursement for the AQ for the PC/TC on the database and this would need to be referenced?
- If the PC/TC indicator is used, what is the indicator # that would apply to the high payment?
- Do I code a PQRI measure if the physician is assisting on a case? I am using modifier -80, but I am unsure if I need to also code one of the measures we use.
The main question I have is regarding reading radiology services after hours from one hospital location for a couple other local hospitals. These are all in the same billing locality. Our radiologists are at one main location here in Green Bay from 5pm until 7am every day. During these hours, they will talk with the techs at the other locations, review progress of images with them and interpret the studies performed on that hospital's equipment. These are either ER dept patients or in-patients. Are we supposed to use the hospital they are physically located at as the POS? If so, it seems odd that we would bill out an "in-patient" charge for one hospital (where the radiologist is located) and the patient is an in-patient at another hospital. The studies won't match up to the patient's hospital stay.
If the patient is seen in the ER and the ER doctor orders a CT scan and they are brought back to the radiology dept for the CT , should we be billing the POS as ER or outpatient? I realize that Medicare doesn't reimburse differently for ER versus outpatient/inpatient, but many of the other insurance carriers want the POS to be the ER in these situations, because their coverage can be different if the treatment was of an emergent nature.
If x-ray films are performed at a clinic across the street from the hospital and brought to the hospital for our radiologists to read, do we use the clinic info (POS 11 for office) or do we use the hospital location (POS 22-outpatient) even though the patient never stepped foot in the hospital?
At the seminar I was told that we could not bill Part B for the Zostavax vaccine, in fact I was told it may be considered abuse. Please advise on correct or acceptable billing for zostavax.
For the most part, our radiologists perform interpretations in their offices - but since the films are all electronic, they can do the interpretations anywhere they have a computer. Occasionally, they will be in the hospital and will sit down at a computer, bring up films and do interpretationss from there. Do we have to have to bill these out with place of service hospital? If so, inpatient or outpatient? How do we know in the billing office, when the doc reads a film at the hospital?
Somewhat related, a few years ago, our organization was instructed that our radiology exams had to state where the exam was interpreted. For example: the bottom of the report would say: "This exam is interpreted at the XXXXX Clinic". Is this really necessary?
Are decimal points allowed in the fields for reporting hematocrit and hemoglobin?
Yes
Can Clinical Social Worker bill Medicare for smoking cessation codes 99406 & 99407?
No
Is the correct code for the administration of the Hepatitis B vaccine, G0010?
Yes, for 2008, the HCPCS book verifies this.
The codes that we are questioning are 90760 and 90774. We occasionally have patient's that will come in for a migraine and they have vomiting and dehydration stemming from the migraine. The provider will give them IV fluids for their dehydration (between 30-60 min's) and then in the meantime will push an IV med. CPT states both 90760 and 90774 are initial codes only. How would we code this?
90774 & 90761 According to the CPT Professional Edition, 90761 is reported to identify hydration if provided as a secondary or subsequent service after a different initial service (90760, 90774, 96409, 96413) is administered through the same IV access. The RVU’s for these services should not be used to determine the order.
Should critical access hospitals be billing Medicare Part D for Zostavax and other non-Part B covered vaccinations?
This is a Part D covered benefit and if the patient has Part D it should be billed to Part D. Contact Part D plans for additional information.
Can you bill chemotherapy infusion and 90772 for the push of another substance (different location) on the same day with a 59 modifier?
Yes, assuring documentation supports the separate sites of service.
Please post a copy of the most current E/M audit sheet.
WPS does not use an audit sheet. The Wisconsin Medical Society does not endorse any one specific audit sheet, but samples can be found here: inpatient or outpatient.
Can you provide evidence of the actual date of service and place of service information? For example, reading radiology tests, etc.
A general rule is to bill the service where the provider actually performed the service and on the day the provider performed the service. There are some exceptions. See scenarios in other Questions and Answers.
Do you need the mammography certification number on claims for the professional component only?
No
If you accept assignment and two years after claims were paid you find out that the patient actually had Medicare primary, is there anyway to get these paid past timely filing?
No
What is the N&E of assignment?
The Nature and Effect of Assignment explains that Assignment is a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to let the physician or other supplier request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. The physician/supplier in return agrees to accept the Medicare allowed payment amount by the carrier as his/her full charge for the items or services. A physician/supplier who agrees to accept assignment on all claims for Medicare services, rather than on a claim-by-claim basis is known as a participating physician/supplier. See Publication 100-4, chapter 1, sections 30.3 and 30.3.12.2 of the IOM. In effect, the physician/supplier who accepts assignment on a claim-by-claim basis or who is a participating physician/supplier is precluded from charging the enrollee more than the deductible and coinsurance based upon the approved payment amount determination. If dissatisfied with the amount of the Medicare allowed amount, a physician/supplier may follow the procedures for appeals of contractor initial determinations. You can read more in Publication 100-4, Chapter 1, Section 30.3.2 found at http://www.cms.hhs.gov/manuals/downloads/clm104c01.pdf.
The following section speaks to what the beneficiary owes on a claim that cannot be paid due to untimely filing:
Excerpted from Publication 100-4, Chapter 1, Section 70.4 70.4 - Determination of Untimely Filing and Resulting Actions (Rev. 830, Issued: 02-02-06, Effective: 07-01-06, Implementation: 07-03-06)
Medicare denies a claim that is not filed timely as specified in §70.1. Medicare determines whether a claim has been filed timely by comparing the date the services were furnished (line item date or claim statement “from” date) to the receipt date applied to the claim when it is received. If the span between these two dates exceeds the time limitation specified in §70.1, the claim is considered to have been not timely filed. When a claim is denied for having been filed after the timely filing period, such denial does not constitute an “initial determination”. As such, the determination that a claim was not filed timely is not subject to appeal. Where the beneficiary request for payment was filed timely (or would have been filed the request timely had the provider taken action to obtain a request from the patient whom the provider knew or had reason to believe might be a beneficiary) but the provider is responsible for not filing a timely claim, the provider may not charge the beneficiary for the services except for such deductible and/or coinsurance amounts as would have been appropriate if Medicare payment had been made.
Can freestanding critical access facilities report PQRI for their physician claims that are filed to Part B?
PQRI codes may be reported for any bill that is submitted and processed under a physician’s number.
Can you append a 50 modifier to an ASC facility charge?
Modifier 50 should be appended on the professional surgical charges for ASC services.
Can you provide additional information on the collapsing of PTAN’s?
http://www.cms.hhs.gov/Transmittals/Downloads/R244PI.pdf
http://www.cms.hhs.gov/MLNMattersArticles/downloads/MM5906.pdf
Is there a reason currently why modifier 76 as opposed to 91 would be required on repeat lab services? (Genetic testing)
Modifier 91 is used for Repeat Clinical Diagnostic Laboratory Testing, not for genetic testing.
Can you provide information on the reporting of both a peripheral and axial bone density study on the same day?
Refer to policy, http://www.wpsmedicare.com/part_b/policy/ms004.pdf>
“There are limited clinical situations, where it may be appropriate to do both axial and peripheral bone mineral density (BMD) studies on the same date of service, or within thirty days of each other. Medicare will not reimburse for both axial and appendicular testing on the same date of service or within thirty days of each other, unless the medical records substantiate that the patient has artificial instrumentation in place in either hip or spine, or other conditions that precludes a reading in those locations. These other conditions may include the following;
- Hip or spine cannot be measured. (Reason must be documented in the medical record).
- Hyperparathyroidism
- Obese patient over the weight limit of the DEXA exam table.
- Extreme arthritic changes which preclude accurate measurement.
What is required as documentation for reporting a level of consultation or E/M based on time? Do you need to document the total time counseling and the total time of the visit (ex: 35 of 45 minutes spent counseling)?
Both Transmittal 788 and the CMS 95 and 97 Documentation Guidelines state “If the level of service is reported based on counseling and/or coordination of care, the total length of time of the encounter should be documented and the record should describe the counseling and/or activities to coordinate care.”
The statement in CMS Publication 100-04, Chapter 12, Section 30.6.1.C states "the duration of the counseling/coordination of care that is provided face-to-face or on the floor may be estimated, but that estimate, along with the total duration of the visit, must be recorded when time is used for the selection of the level of services that involves predominantly coordination of care or counseling.”
The following CPT Assistant articles also discuss documentation of time and indicate the total visit time, total counseling time and summary of the counseling be documented: October 2003 and August 2004.
The best practices method of recording time would be to include the time spent counseling, the total time of the encounter and the details of the counseling and coordination of care provided.
The following questions are on the use of the AQ modifier as it relates to HPSA’s.
- It is my understanding that the incentive (higher payment) is based on the provider's location by zip code. Is this correct?
Yes. Payment is not “higher” for the particular service. A fixed percentage incentive bonus payment is paid to the provider, based on eligible services reported with AQ. - Are there specific codes that are eligible to have the AQ? Does the CMS website indicate those codes that are eligible to have the AQ modifier.
OR, could the RVU indicator determine reimbursement for the AQ for the PC/TC on the database and this would need to be referenced?
Providers may use any reference they deem appropriate to determine if the service is a physician service. - If the PC/TC indicator is used, what is the indicator # that would apply to the high payment?
See previous answer. - Do I code a PQRI measure if the physician is assisting on a case? I am using modifier -80, but I am unsure if I need to also code one of the measures we use.
Surgical procedures billed by an assistant surgeon(s) will be excluded from the denominator population so their performance rates will not be negatively impacted for PQRI. PQRI analyses will exclude otherwise PQRI-eligible CPT Category I codes, when submitted with assistant surgeon modifiers 80, 81, or 82. It is the measure owner’s intention that the primary surgeon, not the assistant surgeon, should be responsible for performing and reporting the quality action(s) in applicable PQRI measures.
Medicare reimbursement is 5% higher for providers that participate versus those that do not participate. The following links contain information on participating, non-participating and opting out of Medicare.
http://www.wpsmedicare.com/part_b/business/med_participation.shtml
http://www.wpsmedicare.com/part_b/business/enroll_opt.shtml
The main question I have is regarding reading radiology services after hours from one hospital location for a couple other local hospitals. These are all in the same billing locality. Our radiologists are at one main location here in Green Bay from 5pm until 7am every day. During these hours, they will talk with the techs at the other locations, review progress of images with them and interpret the studies performed on that hospital's equipment. These are either ER dept patients or in-patients. Are we supposed to use the hospital they are physically located at as the POS? If so, it seems odd that we would bill out an "in-patient" charge for one hospital (where the radiologist is located) and the patient is an in-patient at another hospital. The studies won't match up to the patient's hospital stay.
For the situation you described, you should follow the classification of the patient since a facility is involved, Therefore, if the patient is inpatient -21, outpatient - 22 or Emergency Room - 23. Medicare guidelines state you should report the address and zip code of the physical location of where the radiologist is performing services on the claim form.
If the patient is seen in the ER and the ER doctor orders a CT scan and they are brought back to the radiology dept for the CT , should we be billing the POS as ER or outpatient? I realize that Medicare doesn't reimburse differently for ER versus outpatient/inpatient, but many of the other insurance carriers want the POS to be the ER in these situations, because their coverage can be different if the treatment was of an emergent nature.
Once again, you should follow the classification of the patient since a facility is involved. For this situation, you should bill POS ER - 23. Medicare guidelines state you should report the address and zip code of the physical location of where the radiologist is performing services on the claim form.
If x-ray films are performed at a clinic across the street from the hospital and brought to the hospital for our radiologists to read, do we use the clinic info (POS 11 for office) or do we use the hospital location (POS 22-outpatient) even though the patient never stepped foot in the hospital?
This patient is not a facility patient. Report the POS to indicate the place where he radiologist is reading the x-ray film. Medicare guidelines state that you should report the address and zip code for the physical location of place where the radiologist performed his/her service.
At the seminar I was told that we could not bill Part B for the Zostavax vaccine, in fact I was told it may be considered abuse. Please advise on correct or acceptable billing for zostavax.
Since Zostavax is not covered by Medicare Part B, it is not necessary to submit a claim, nor should the provider routinely submit a claim to Medicare Part B for this service. Only in those infrequent situations such as the beneficiary does not have Medicare Part D, should a claim for Zostavax be submitted to Medicare Part B.
For the most part, our radiologists perform interpretations in their offices - but since the films are all electronic, they can do the interpretations anywhere they have a computer. Occasionally, they will be in the hospital and will sit down at a computer, bring up films and do interpretationss from there. Do we have to have to bill these out with place of service hospital? If so, inpatient or outpatient? How do we know in the billing office, when the doc reads a film at the hospital?
The physician should bill using the physical location and zip code of where they perform the services. This corresponds to the Box 32 information. As far as place of service, if the patient is an inpatient, then they should use POS 21. If the patient is not and they are in the outpatient department, they can use POS 22.
Somewhat related, a few years ago, our organization was instructed that our radiology exams had to state where the exam was interpreted. For example: the bottom of the report would say: "This exam is interpreted at the XXXXX Clinic". Is this really necessary?
WPS Medicare is not aware that this is a current requirement.
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