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I have been having problems getting my re-evalutions paid. The last re-evalution I billed was the code 99211 with the modifier-25 to show it was a distinct procedure separate from my adjustment code. According to my payer, one initial exam is covered and one re-exam per episode is covered. They have informed me the 99211 code is not a valid code and can only be used one time in a 60 day period. The patient is an established patient. Any suggestions?
Answer:
Most payers will not recognize such a low level E/M code such as 99211, which is hardly a re-examination at all! Payers expect regular re-examintations, but we suggest doing a more in-depth evaluation and using a higher E/M code such as 99212 or 99213. Please note also the requirements for these higher-level exams. For example, 99213 requires both an expanded problem focused history and exam. See page F-27 in your 2010 ChiroCode DeskBook for a clear explanation of what is required for each key component of E/M code selection.
As for the payer only covering one new patient and one re-exam, review your contract. If this is one of their policies and you are in-network, you may be at their mercy.
In regards to code 98943 for extraspinal adjustments, when adjusting more than one extremity per visit, how is that coded? Do I list one code with three units, or as three different diagnoses with one unit each?
Answer:
On page F-86 of your 2010 ChiroCode DeskBook the CPT description for 98943 states, “Extraspinal, 1 or more regions.” Since the code specifically states "1 or more regions," you can only bill one unit of 98943 no matter how many extremities you adjust. This is true for all CPT codes that include "1 or more regions" in the description.
To support your claim, you can and should document all the diagnoses in the patient’s chart.
In some instances when the patient receives both spinal (98940-98942) and extra-spinal manipulative treatment (98943) on the same day, the 98943 service could be appended with the modifier -51 (e.g., 98943-51). Use this modifier with care and with knowledge of payer policies.
See page F-113 in your 2010 ChiroCode DeskBook for more information about modifier -51 for multiple procedures.
I am very confused about Par and Non-Par fees. Am I not able to bill seniors the same amount as my regular patients if I wanted to?
Answer:
"PAR" and "Non-PAR" refer to a practitioner's participation status within the Medicare program. If you are PAR, you can bill your usual fee, but Medicare will discount it to the Allowed Amount, and you cannot balance bill the patient beyond the Allowed Amount. If you are Non-PAR, you cannot bill more than the Medicare Limiting Charge for unassigned claims, which is 109.25% of the Allowed Amount. If your Non-PAR charge is less than the Limiting Charge you have nothing to worry about.
Followup Question: Does this mean that if we are Non-PAR we can only charge...say...the 30 dollars Medicare allows? What if we do other services?
Answer: Yes, you may only charge up to, but not more than the Limiting Charge for Medicare covered services (the three CMT codes). All other services are non-covered and beyond Medicare law or concerns.Accordingly, you charge use your usual fee for non-covered services.
How should I bundle and bill these procedures? I need to know how to bill them correctly so I don't have to go through an appeal process. The codes are 98940 for less than two regions, 98943 for TMJ and jaw dislocation, and a code for manual traction 15+ minutes, which I have not yet found. I was going to bill the 98940 with the -AT modifier and the 98943 and the manual traction code when I found one with the -25 modifier, or maybe the -51 modifier. I am unsure of which to use.
We would like to start billing for report of
findings using the proper documentation. We would also like to go through the
past year or so and bill for all of the previous reports as well. How legal is
this and is there an expiration on how far back I can bill?read more...
If an insurance
company requests notes on a patient for a particular visit, may we charge the
insurance company for those notes?Also,
if we need to send the notes for a precertification, such as with Landmark
Healthcare, can we charge them for the notes and processing the forms needed?read more...
We
have been using the code "G0283" for electrical stimulation but want
to make sure that is the correct code. In the past we were using the
"97014". Which one is correct?
What is the appropriate code for a cervical traction unit (roll with weighted water bag) used in conjunction with a chin/ head harness–not over the door but used in a supine position. read more...
I’m confused about what constitutes the 98940 to 98943 codes. Do they describe the number of body regions ADJUSTED or the number of regions that the patient’s complaints encompass? read more...
We bill code 97110 for therapeutic exercises. All but one insurance company pays this code in time units. Can the insurance company refuse to pay for units of time performed for therapeutic exercises? read more...
Our insurance billers are really good at talking to the claims payers. On more than one occasion they have convinced Medicare Representatives to make changes and correct claims. I had never heard of anyone who was able to get a Medicare Representative to do anything without a resubmission or appeal. What is the big secret? read more...
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