Anesthesia Billing for CRNAs

When filing claims through the Medicare program and the CRNA is employed by the anesthesiologists, reimbursement for “medically directed” by an anesthesiologist and “non-medically directed” are revenue neutral - meaning reimbursement is equal to the same amount.  

For example, when medical direction modifiers “QK and QX” are reported (see table below), reimbursement is divided equally (50% and 50%) between the physician and the CRNA.  When a CRNA is non-medically directed, full reimbursement (100%) is paid. It is a misconception that an MD/CRNA care team must report Medicare modifiers to all insurance companies, and doing so may cause reimbursement problems.  

Not all carriers recognize separate claims or Healthcare Common Procedure Coding System (HCPCS) modifiers!  

Many private insurers expect CRNA services to be billed under the anesthesiologist, on one line of the claim form. Reporting separately may result in a claim denial or improper payment.  An additional confusion, since many practices generally equally split the full amount of the bill between the physician and CRNA, is that the claim is viewed as a duplicate.  

Although Medicare pays the CRNA and anesthesiologist equal shares, other carriers may not pay the separate charge, leaving your patient with a large out-of-pocket expense.

One way to avoid confusion when you must bill two claims, i.e. to collect a Medicare secondary balance, is to charge different amounts for the physician and CRNA.  

For example, in our practice we assigned 70% of the conversion factor to the physician and 30% to the CRNA; however, your practice may choose to assign a different value.    

Assigning different values when claims must be split helps identify and separate the services of the physician and the CRNA, as well as decrease odds the claims will be mistaken as duplicate.  It is important to remember, however, not to assign a CRNA value so low that the submitted charge is less than the allowed or expected amount!

How can you tell when to send separate claims?  

One clue is to determine whether a separate provider number is needed, such as Tricare, which does credential CRNAs. To receive payment from carriers that require two claims, the CRNA must have a valid provider number and have reassigned their benefits.  It is important to ensure the provider number is valid before the CRNA begins working.  

Many practices lose revenue by their inability to bill certain insurances, such as Medicare and Medicaid, for a CRNA whose number is not yet in place, such as temporary providers.  Although short-term contract or temporary CRNAs are called “locum tenens,” the locum tenens modifier is not intended to be used to bill for their services.

In most instances, CRNAs are prohibited from using the Q6 modifier to receive payment, since by definition the modifier indicates the service was provided by a “physician.” However, as to be expected in the anesthesia world of billing, there are no “absolutes”! Georgia Medicare published policy in September of 1999, which specifically allows use of the Q6 modifier by CRNAs. 

Keep in mind, though that without written permission this is generally not an acceptable use of the Q6 modifier.

base units of Anesthesia cpt code - list 2

CPT CODES and BASE UNITS

CPT CODES and BASE UNITS

00930 4 00932 4 00934 6 00936 8 00938 4 00940 3 00942 4 00944 6 00948 4 00950 5 00952 4 01112 5 01120 6 01130 3 01140 15 01150 10 01160 4 01170 8 01173 12 01180 3 01190 4 01200 4 01202 4 01210 6 01212 10 01214 8 01215 10 01220 4 01230 6 01232 5 01234 8 01250 4 01260 3 01270 8 01272 4 01274 6 01320 4 01340 4 01360 5 01380 3 01382 3 01390 3 01392 4 01400 4 01402 7 01404 5 01420 3 01430 3 01432 6 01440 8 01442 8 01444 8 01462 3 01464 3 01470 3 01472 5 01474 5 01480 3 01482 4 01484 4 01486 7 01490 3 01500 8 01502 6 01520 3 01522 5 01610 5 01620 4 01622 4 01630 5 01634 9 01636 15 01638 10 01650 6 01652 10 01654 8 01656 10 01670 4 01680 3 01682 4 01710 3 01712 5 01714 5 01716 5 01730 3 01732 3 01740 4 01742 5 01744 5 01756 6 01758 5 01760 7 01770 6 01772 6 01780 3 01782 4 01810 3 01820 3 01829 3 01830 3 01832 6 01840 6 01842 6 01844 6 01850 3 01852 4 01860 3 01916 5 01920 7 01922 7 01924 6 01925 8 01926 10 01930 5 01931 7 01932 7 01933 8 01935 5 01936 5 01951 3 01952 5 + 01953 1 01958 5 01960 5 01961 7 01962 8 01963 10 01965 4 01966 4 01969 5 01990 7 01991 3 01992 5

00100 5 00102 6 00103 5 00104 4 00120 5 00124 4 00126 4 00140 5 00142 6 00144 6 00145 6 00147 6 00148 4 00160 5 00162 7 00164 4 00170 5 00172 6 00174 6 00176 7 00190 5 00192 7 00210 11 00211 10 00212 5 00214 9 00215 9 00216 15 00218 13 00220 10 00222 6 00300 5 00320 6 00322 3 00326 8 00350 10 00352 5 00400 3 00402 5 00404 5 00406 13 00410 4 00450 5 00452 6 00454 3 00470 6  00472 10 00474 13 00500 15 00520 6 00522 4 00524 4 00528 8 00529 11 00530 4 00532 4 00534 7 00537 10 00539 18 00540 12 00541 15 00542 15 00546 15 00548 17 00550 10 00560 15 00561 25 00562 20 00563 25 00567 18 00566 25 00580 20 00600 10 00604 13 00620 10 00622 13 00625 13 00626 15 00630 8 00632 7 00634 10 00635 4 00640 3 00670 13 00700 4 00702 4 00730 5 00740 5 00750 4 00752 6 00754 7 00756 7 00770 15 00790 7 00792 13 00794 8 00796 30 00797 11 00800 4 00802 5 00810 5 00820 5 00830 4 00832 6 00834 5 00836 6 00840 6 00842 4 00844 7 00846 8 00848 8 00851 6 00860 6 00862 7 00864 8 00865 7 00866 10 00868 10 00870 5 00872 7 00873 5 00880 15 00882 10 00902 5 00904 7 00906 4 00908 6 00910 3 00912 5 00914 5 00916 5 00918 5 00920 3 00921 3 00922 6 00924 4 00926 4 00928 6

Get More Patients for Your Medical Practice

When medical students are concentrating on preparing for anatomy tests and attempting to remember endless lists of diseases and conditions, I doubt the thought of “How will I get patients in my door?” ever crosses their minds.

I read a blog the other day with a few suggestions on how hospitals should utilize their website to bring patients in to their facility. 

There are usually not hospitals on every corner whereas, it can seem like you can’t throw something and miss a physician’s office. 

This increases the competition for patient business exponentially over that of hospitals.  So if a “business machine” like a hospital needs help with their “web presence” to entice patients, private practice physicians must be in dire straits in that department.

The suggestions posted for hospitals were: provide a toll-free customer support number, add trust indicators, and include testimonials.

I think with some minor adaptations we can follow their reasoning and come up with some good suggestions to increase the flow of customers to your medical practice.

I do not see any advantage to a toll-free number, but a prominently displayed contact number and address with available directions is very important content for your website.

I also suggest avoiding the “press a number for your party and leave a message” as the only option with your automated telephone answering system.  People like to speak to humans, always have this as an option.                                                                                                                                                         

Your credentials are another highly valuable addition to your website. At the bare minimum, provide details of your professional degrees as well as internship, fellowship and residency completions.  Patients are interested in their physicians’ training and will have increased confidence when able to easily see this information.

You can really impress patients by also including any medical publications you have authored, lectures or teaching participations, etc.  It’s perfectly okay to boast a little, be proud of the knowledge and expertise that you can provide for your patients.

When patients love their doctor, they love to tell other people.  If you have some particularly enthusiast patients, go ahead, ask for a testimonial.  Just be sure to keep to a first name basis for privacy sake, like: Sally says, “I am so happy I found Dr. Smith.  I have never felt better.”

Physician referrals and “industry” word of mouth are significant factors patients consider when selecting a provider.  Always try to cultivate good professional relationships with local hospitals and other physicians and don’t forget to “return the favor” for those who regard highly as well.

See the Medical Business Systems website for more insight on creating a successful medical practice with Iridium Suite Practice 

Do Medical Billers Make New Year's Resolutions?

As made fact by the all-knowing Google search, these are the typical top 10 New Year’s Resolutions in no particular order:

Eat Healthy/Exercise Regularly exercise improves health / Drink Less : Learn Something New continued education / Better Work/Life Balance Quit Smokingquit smokingSave Money   save money / Volunteer / Get Organized   organizational tools Read More reading Finish To-do Listto do list

So if you are sitting in your billing office, looking ahead to 2014, your list of resolutions might look similar to those below.  Iridium Suite Practice Management Software wants to help you keep your medical billing resolutions.  We offer free access to informative blog articles, user forums, healthcare infographics, white papers and ebooks.

Learn how to use ICD-10… I have until October 1! continued education. Increase revenue by analyzing fee schedules and negotiate better reimbursements. save money reading Read newsletters and healthcare articles to keep up with billing changes like new CPT codes, additional PQRS measures, claims filing rules (like the new HCFA 1500 format and quarterly CCI edits)

Organize my EDI transactions to maximize new payer ERA and EFT mandates. organizational tools to do list Keep up with those dreaded tasks like patient accounts receivables follow-up.

Value Based Healthcare:

I have an “email subscription” to the TED lecture series.  Each day I receive a notice with a link to a new video lecture that has been posted.  Some days, especially the very busy ones, I don’t even open the email.  If I do not perceive the title to be worthy of the 15-20 minutes of my time, I immediately delete it.  One title struck me as extremely worthy, I took the time to listen, and ta da here I am writing this post.

My inspiration was this lecture byphysicianStefan Larsson: What doctors can learn from each other.

Hopefully you have time to watch this lecture.  Anyone in the US healthcare industry should.  We Americans typically think we have cornered the market on being the best at everything.  Sometimes we need to be reminded we are not and even if you are the best, there is almost always room for improvement.  

The improvement needed, which is pointed out so eloquently in this lecture is the idea that value based medical healthcare works!

Questions about value based healthcare: The following 5 questions and answers will provide a brief primer on value based healthcare.

What does value based healthcare mean?  

It is a relatively simple concept.  By switching the focus to the best patient care, costs are typically reduced in the long run, providing the highest “value” for the service. 

  

Think about when you buy a new TV.  You can get the “generic” brand for half the price of a “name” brand, but it lasts 2 years and the name brand lasts 5.  There is more value in the “name” brand. 

Who will be impacted by this new payment model?  

The Affordable Care Act requires CMS to establish a value-based payment modifier that provides for differential payment to a physician or group of physicians under the PFS based upon the quality of care furnished to Medicare beneficiaries compared to the cost of that care during a performance period. 

For CY 2015 groups of physicians with 100 or more eligible professionals are subject to the value-based payment modifier.  The limit will be significantly reduced in CY 2016 to groups of physicians with 10 or more eligible professionals.  

It is estimated that this lowered threshold will cause approximately 17,000 groups and nearly 60 percent of physicians to be included in the value-based payment modifier program in CY 2016. (Groups of physicians with 100 or more eligible professionals could receive either upward or downward adjustments.  However, only upward adjustments will be applied to groups of physicians with between 10 and 99 eligible professionals.)

Commercial payers are also creating processes and protocols to follow suit with implementing value based healthcare. 

Where will the data come from?  

CMS collects and analyzes data via the PQRS program.   A recent survey published by Availity™, shows that commercial payers as well as providers have growing concerns over the ability to exchange the necessary health information in an automated fashion. 

How will the value of the care be measured? 

Current plans include utilizing data collected via PQRS performance.  The Medicare Spending per Beneficiary (MSPB) measure may be included as an additional measure in the cost composite of the value-based payment modifier beginning with CY 2016.

When should I expect this to occur?  

Part of theACA statute requires that CMS begins applying the value-based payment modifier on January 1, 2015, with respect to items and services furnished by specific physicians and groups of physicians (as determined by the Secretary) and to apply it to all physicians and groups of physicians beginning not later than Jan. 1, 2017.  

CMS website : The CMS website provides more extensive information on the Physician Value-based Payment Modifier.

Hot Off the Press: Cancer Rates Dropping

Are You Optimizing Your EDI Functionality?

When Medical Billing Software is Better Than Bacon.

The smell of bacon cooking can trigger such pleasant memories as weekend family breakfasts.  The smell must be so intoxicating that someone even created bacon scented deodorant. (Go ahead google it, I dare you or go to powerbacon and buy yours today.)

The taste, always salty, sometimes sweet, occasionally spicy, will make your mouth water and turn ordinarily dull toast, lettuce and tomato into a tantalizing lunch.

“As seen on TV”, the ever amazing bacon can be turned into an edible bowl you can fill with foods of your heart’s delight.

It is so popular, websites, Facebook and Google+ pages have been dedicated to it.  If you don’t believe me, see Mr. Baconpants.

But, even with all those things going for it, Iridium Suite Practice Management Software is better.

You can’t eat software, but the right one will improve your cash flow and that equals more bacon (the figurative kind and the real stuff) and/or wine, shoes, hobbies, whatever your desires might be!

So see, I am right.  Medical billing software is better than bacon.

Choose  and let us help you “Bring home the bacon!”

Contact us for your free demo today!

In the meantime, let me explain how Iridium Suite can help you to achieve maximum claim reimbursement.

The critical elements are submitting clean claims initially, receiving quick insurance payments, monitoring denials, collecting patient payments and analyzing business performance indicators through reporting.

You can fulfill all these tasks with the following functions found in Iridium Suite:

Real-time Eligibility:  This function will allow staff to check patient eligibility in "real-time" before services are invoiced to the payer.  It eliminates denials for terminated policies or rejections due to incorrect identification numbers, etc.

Claim Scrubber: To prevent denials based on the NCCI edits, you will have the ability to "scrub" claims for conflicts between the procedures being billed.  We also offer custom scrubber rules that can be designed especially for your practice/specialty.

Integrated Electronic Invoicing: You are able to submit of the majority of your payer claims electronically which provides accelerated claims processing.  Denials for untimely filing can cost your practice significant revenue.  Electronic claims submission also offers automated responses from the clearinghouse and the payer recorded in the system.  You can produce these responses as a PDF document called “Proof of Timely Filing Report” to back up your appeals for those types of denials.  Electronic invoicing also drastically reduces the number of claims lost in the mail or “not on file at the payer.”

Automated Electronic Payment Adjudication:  The software is able to automatically adjudicate electronically received insurance explanation of benefits.  Through this process, insurance payments are posted faster allowing you to quickly collect remaining balances from secondary payers or patients and initiate any appeals for any denied services.

Practice Management Tools:  With a full ranges of accounts receivable and revenue reports, as well as, practice statistics you can keep on top of any potential reimbursement issues and provide the accountability your providers require.

Claim Scrubber Optimizes Radiation Therapy Claims Reimbursement

Radiation oncology billing is especially difficult because of the planning and staging processes that occur prior to treatment. On a bad day a coder can create future problems that are difficult to remedy.  Fortunately, Iridium Suite offers a safety net to help you avoid the pitfalls of improper coding.

A claim scrubber is a built-in editor, like spell check, except it is automatic. Iridium Suite medical system software features a scrubber that has many capabilities, so a biller can be confident that many billing violations will be caught by the claim scrubber before the claim is generated.  

The claim scrubber is present and active in the background during billing work, whether during the importing of charges from outside systems (such as record and verify systems or EMR's/EHR's) or while manually coding charges.

Here are a few examples of the functions of Iridium Suite’s claim scrubber:

The claim scrubber offers suggestions for converting old, outdated codes to newer ones, or requests permission to add a modifier to an E & M (evaluation and management) code that conflicts with other codes billed the same day, such as 99204 with 77263.  

The biller has the option of re-evaluating the code and overriding the warning edit or allowing the scrubber to change it.

The claim scrubber sets a warning status on service lines that may be correctly coded but which conflict with other services according to NCCI (National Correct Coding Initiative) edits. 

A pop-up window shows the NCCI conflict and rule regarding the services billed. The biller has the option of choosing to override the warning status or the biller can change the date on the service that is being billed to avoid the conflict. The service line may also be deleted and a more appropriate service can be coded.  

PQRI/PQRS is a potential ‘miss’ on any patient having Medicare or Medicaid.  If a medical practice activates the PQRS scrubber, then the scrubber is configured to automatically request that the physician sets up PQRS measures for each patient whose treatment qualifies for PQRI. 

The claim scrubber also recognizes which billing codes are potential PQRS denominators and automatically suggests the PQRS numerator codes that should be added to the claim. The biller simply accepts these suggestions and the claim scrubber automatically adds the proper PQRS charge codes to the claim.

In addition, the Iridium Suite claim scrubber makes every radiation oncology biller’s life better by automatically adding up the patient’s daily treatments and applying the management code 77427 with its corresponding dates. This feature is a fantastic time saver and ensures that this often-forgotten code is billed out properly.

Iridium Suite’s claim scrubber is only one of the many ideally designed tools integral for the best radiation oncology medical practice billing software available. It saves time and money and prevents potential errors that delay receipt of your claim reimbursement.

Now What Was I Supposed To Do?

Recent news stories have relayed studies that proclaim the numerous and varied health benefits of drinking coffee.  About 83% of adults in the US drink coffee.  Many drink it for that “boost of energy” provided by the caffeine.  An average size cup in 9 ounces contains about 200 mg of that key ingredient. According to one such story that caffeine may do more than perk you up; it may also improve your memory.

caffeine improves memory

Since I do not work for any coffee consortium or own stock in some coffee shop chain store, my intent is not to have you drink more coffee, but instead to think about memory.  More specifically, what you have to remember to do when you are performing your daily medical billing tasks.

In no particular order:

Check charge slips received or codes captured against the appointment schedule

Verify documentation has been completed for the service provided

 Add modifiers as required by CCI edits

Verify appropriate authorizations are in place and attached to charges accordingly

Collect co-pays at time of service

Generate daily, monthly, quarterly, etc. reports

Import and adjudicate ERA files

Review EOBs for service denials

Enter in charges from charge slips or from data in the EMR

And the list goes on and on as you know.

So, what can help you to get all these things done and ease up the pressure on your memory?  The advanced features of Iridium Suite Practice Management Software can.  Listed below are some of the key functions of this medical billing system that will keep you from needing an IV infusion of that aromatic brew.

The Connectivity Clearinghouse enables connections to multiple EHR systems. You can connect to your EHR as often as your office work flow dictates. With accurate and complete data entry in your EHR, you are able to bring in all the necessary information to bill and file your patient claims.

The Report Center Module of the billing software allows the user to format, save and schedule reports that are automatically sent to your email.  Reports such as “Chargeless Accounts” and “Scheduler Discrepancy Report” can be auto-created daily to use as a check list against missing charges.

The EDI functions found in billing system provides access to Real Time Eligibility and electronic claim submittals for hundreds of payers. It will also automatically adjudicate ERAs received from the ACH with little to no user interaction.

 The Accounts Receivables module of Iridium Suite enables a “paperless” review system for both payers and patients.  This eliminates that unsightly desktop mess and provides the manager the ability to “electronically assign” selected open ARs to office staff for appropriate follow up.

 A built-in Claim Scrubber automatically checks against current CCI edits as well as providing the user with customizable, practice specific rules that can be applied as defaults to all payers or made payer specific.

  The To-Do reminder function found in the practice management software, gives each user the ability to create an electronic “sticky note” for themselves or other users.  This function is extremely useful for staff in need of collecting money or insurance information from incoming patients.

practice management Take Dr. Ernie’s advice, keep your caffeine intake moderate and let Iridium Suite do the remembering for you!

Medicare Medical Billing Newsletter Has Important Information for Primary Care Physicians

As a Primary Care Physician you probably generate numerous claims for Annual Wellness Visits for your Medicare Beneficiaries. If you are an outpatient hospital/facility based provider, you need to be aware of the upcoming changes for the payment of HCPCS G0438 and G0439.

Under current claims reimbursement processes, a preventive service that has been submitted for both a “professional” service (the professional claim for the delivery of the service itself) and a “technical” service (the institutional claims for a facility fee)for the same day, payment is allowed for both. Review of this process has identified overpayments in some case and future recoupments will be initiated.

To remedy this, new claims processing regulations become effective for claims processed on or after April 1, 2013 allowing payment for either the practitioner or the facility for furnishing the AWV.

This regulation in based on the fact that codes G0438 and G0439 have no separate payment for a facility fee. The claim will be posted to the Medicare beneficiary's utilization history and processed/reimbursed as the “professional” service only, regardless of whether it is paid on a professional claim or an institutional claim. 

Note: Only one payment for the AWV will be allowed on the same date and paid on the first claim received. 

Recommendation: If you are performing AVW's in a facility, you should discuss these billing changes with them immediately. It is necessary to come to an amicable and mutally agreed upon approach to which entity will be submitting the claims for these services and how the reimbursement would be distributed to both parties. By planning ahead, you will be preventing any possible difficulties in your working relationship with the facility.

Medicare Payment Reductions for Diagnostic Cardiovascular, Imaging and Ophthalmology Proceduresvascular, Section 3134 of the Affordable Care Act added Section 1848(c)(2)(K) of the Social Security Act which specifies that the Secretary shall identify potentially misvalued codes by examining multiple codes that are frequently billed in conjunction with furnishing a single service. 

As a further step in implementing this provision, Medicare is making a change to the MPPR on the PC and TC of certain diagnostic imaging procedures and to the TC of diagnostic cardiovascular and ophthalmology procedures.

See below for details:                                             

Application of the Multiple Procedure Payment Reduction (MPPR) on Imaging Services to Physicians in the Same Group Practice 

http://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/Downloads/MM7747.pdf

Currently, the MPPR applies only when an individual physician furnishes multiple services to the same patient, in the same session, on the same day. 

The Centers for Medicare & Medicaid Services (CMS) is expanding the MPPR of imaging services by applying it to physicians in the same group practice (same Group National Provider Identifier (NPI)) who furnish multiple services to the same patient, in the same session, on the same day.

The MPPR on certain diagnostic imaging services applies to Professional Component (PC) and Technical Component (TC) services. It applies to both PC-only services, TC-only services, and to the PC and TC of global services. Full payment is made for each PC and TC service with the highest payment under the Medicare Physician Fee Schedule (MPFS). 

Payment is made at 75 percent for subsequent PC services furnished by the same physician group, to the same patient, in the same session, on the same day. Payment is made at 50 percent for subsequent TC services furnished by the same physician group, to the same patient, in the same session, on the same day. 

The individual PC and TC services with the highest payments under the MPFS of globally billed services must be determined in order to calculate the reduction.

The complete list of codes subject to the MPPR on diagnostic imaging can be found in Attachment 1 of CR7747, which is available on the CMS website at:

http://www.cms.gov

Multiple procedure payment reduction on the technical component of diagnostic cardiovascular and ophthalmology procedures

The MPPRs on diagnostic cardiovascular and ophthalmology procedures apply when multiple services are furnished to the same patient on the same day. The MPPRs apply independently to cardiovascular and ophthalmology services. The MPPRs apply to TC only services, and to the TC of global services.

For cardiovascular services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 75 percent for subsequent TC services furnished by the same physician or physician group to the same patient on the same day.

For ophthalmology services, full payment is made for the TC service with the highest payment under the MPFS. Payment is made at 80 percent for subsequent TC services furnished by the same physician or physician group to the same patient on the same day.

The MPPRs do not apply to professional component (PC) of diagnostic cardiovascular and ophthalmology services.

The complete lists of codes subject to the MPPRs on diagnostic cardiovascular and ophthalmology procedures are in Attachments 1 and 2 of CR 7848 respectively. CR 7848 can be found on the CMS website at:

http://www.cms.gov

Billing Hint:

Medicare is applying the MPPR to physicians in the same group practice who furnish multiple services to the same patient, in the same session, on the same day. Medicare will assume procedures furnished on the same date of service were furnished in the same session unless the provider uses modifier 59 to indicate multiple sessions, in which case the reduction does not apply.  If multiple sessions did occur, explicit and detailed documentation will be required in case of an audit of the billed services.

Fee Schedule Information:

To accommodate implementation of this new proposal for certain bill types, the 2013 Medicare physician fee schedule will include the following changes:

1. A new multiple procedure (Field 21) value of ‘6’ will denote diagnostic cardiovascular services subject to the MPPR methodology.

2. A new multiple procedure (Field 21) value of ‘7’ will denote diagnostic ophthalmology services subject to the MPPR methodology.

Explanation of Benefits Information:

When payments are reduced due to the MPPR, you will receive a claim adjustment reason code of 59 (Processed based on multiple or concurrent procedure rules. (For example multiple surgery or diagnostic imaging, concurrent anesthesia,) 

Note: Refer to the 835 Healthcare Policy Identification Segment (loop 2110 Service Payment Information REF), if present.) and group code CO (contractual obligation).