Monthly Archives: July 2016

Official update of the HCPCS code system

HCPCS codes update Effective April 1, 2016

G Codes

Code G9490 – Joint replacement model – Home visit

Code G9481 – Remote in-home visit for the E & M of a new patient 10mins

Code G9482 – Remote in-home visit for the E & M of a new patient 20mins

Code G9483 – Remote in-home visit for the E & M of a new patient 30mins

Code G9484 – Remote in-home visit for the E & M of a new patient 45mins

Code G9485 – Remote in-home visit for the E & M of a new patient 60mins

Code G9486 – Remote in-home visit for the E & M of an established patient 10mins

Code G9487 – Remote in-home visit for the E & M of an established patient 15mins

Code G9488 – Remote in-home visit for the E & M of an established patient 25mins

Code G9489 – Remote in-home visit for the E & M of an established patient 45mins

Code G9678 – Oncology Care Model service

HCPCS code Effective July 1, 2016

Code C9458  – Replaced with HCPCS code Q9983 (Florbetaben f18, diagnostic, per study dose, up to 8.1 millicuries)

Code C9459 – Replaced with HCPCS code Q9982 (Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries)

Code C9743 – Replaced with Category III CPT code 0438T (Transperineal placement of biodegradable material, peri-prostatic (via needle), single or multiple, includes image guidance)

New HCPCS codes

Q9981 – Rolapitant, Oral, 1mg

Q9982 – Flutemetamol F18, diagnostic, per study dose, up to 5 millicuries

Q9983 – Flutemetamol F18, diagnostic, per study dose, up to 8.1 millicuries

S0285 – Colonoscopy consultation performed prior to a screening colonoscopy procedure

S0311 – Comprehensive management and care coordination for advanced illness, per calendar month

S3854 – Gene expression profiling panel for use in the management of breast cancer treatment

Q5102 – Injection, Infliximab, Biosimilar, 10 mg

Modifier ZB – Pfizer / Hospira

New Hospital Outpatient Prospective Payment System (OPPS) pass through drug code

Code C9476 – Injection, daratumumab, 10 mg

Code C9477 – Injection, elotuzumab, 1 mg

Code C9478 – Injection, sebelipase alfa, 1 mg

Code C9479 – Instillation, ciprofloxacin otic suspension, 6 mg

Code C9480 – Injection, trabectedin, 0.1 mg


Reporting Medicare for faster reimbursements with ABN modifiers

How to report Medicare related to Advance Beneficiary Notifications Modifiers

CMS’ coding modifiers are not always used to report clinical components of a service.  Sometimes they can be used in a hospital to provide information about how a service relates to Medicare coverage policies.

When You Must Issue an ABN

You must issue an ABN when you expect Medicare may deny payment for an item or service because:

  • It is not considered reasonable and necessary under Medicare Program standards;
  • The care is considered custodial;
  • Outpatient therapy services are in excess of therapy cap amounts and do not qualify for a therapy cap exception;
  • A beneficiary is not terminally ill (for hospice providers only); or
  • A beneficiary is not homebound or there is no need for intermittent skilled nursing care (for home health services only).

Additional mandatory requirements apply to durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) suppliers. An ABN must be issued before DMEPOS suppliers furnish a beneficiary with an item or service that will not be paid for by Medicare because:

  • The provider violated the prohibition against unsolicited telephone contacts;
  • The supplier has not met supplier number requirements;
  • The supplier is a non-contract supplier furnishing an item listed in a competitive bidding area; or
  • Medicare requires an advance coverage determination, and the beneficiary wants the item or service before the advance coverage determination is made.

Claim Reporting Modifiers:-

Modifier -GA is used to indicate that a waiver of liability statement that is required by the payer is on file.

Modifier -GX is used to describe a voluntary waiver of liability.

Modifier -GY is used to describe an item or service that is statutorily excluded or that does not meet the definition of any Medicare benefit.

Modifier -GZ is used to describe an item or service expected to be denied as not reasonable and necessary.

Why and When is Advance Beneficiary Notifications

An Advance Beneficiary Notice (ABN) is a notice that the provider must provide to a Medicare beneficiary before providing certain items or services.

  • You believe Medicare may not pay for an item or service
  • Medicare usually covers the item or service
  • Medicare may not consider the item or service medically reasonable and necessary

for this patient in this particular instance

ABNs are issued only to those patients who are enrolled in Original Fee-For-Service Medicare.  These documents allow patients to make informed decisions about whether to receive services and to accept financial responsibility for those services if Medicare does not pay for them.  The ABN serves as proof that the beneficiary knew prior to receiving the service that Medicare might not pay for it.

This ABN can also be used as a voluntary notice to alert patients of their financial liability prior to providing medical services that Medicare never covers.  An ABN is not required to bill a patient for an item or service that is not a Medicare benefit and is never covered.

There are exceptions to this rule, however: ABNs may be routinely issued in the following circumstances:

  • Experimental items and services
  • Items and services with frequency limitations for coverage
  • Medical equipment and supplies denied because the supplies had no supplier number or the supplier made an unsolicited telephone contact
  • Services that are always denied for medical necessity

Modifier -GA claims payment and processing

  • Medicare systems will automatically deny lines submitted with the -GA modifier and covered charges on institutional claims
  • Medicare systems will assign beneficiary liability to claims automatically denied when the -GA modifier is present
  • Medicare will use claim adjustment reason code 50 when denying lines due to the presence of the -GA modifier
  • Hospitals must issue an ABN to the beneficiary prior to providing care that Medicare may not cover because it is not medically reasonable and necessary in this particular case
  • Medicare permits hospitals to bill the patient if the patient has signed a valid ABN indicating his or her choice to get the item or service and accept financial liability
  • If the hospital does not issue an ABN or Medicare finds the ABN invalid, that patient may not be billed
  • Hospitals may not use ABNs to charge for a component of a service when Medicare makes full payment through a bundled payment (e.g., a fluoroscopy that is bundled into an injection procedure may not be billed to the patient since its payment is included in reimbursement for the injection)
  • Medicare prohibits providers from using an ABN to transfer liability to the beneficiary when Medicare would otherwise pay for items and services
  • When you issue the ABN as a voluntary notice (modifier -GX), the beneficiary does not check an option box or sign and date the notice
  • The ABN is issued for items and services covered under Part B

Persistence is required to taste the hassle free reimbursement

Couple of decades ago Healthcare physicians considered credentialing is the procedure for enrolment with an insurance company’s preferred provider.  Now a days, it’s mandatory than ever for physicians and healthcare providers including nurses, chiropractors, psychologists, counselors, LCSW’s and many others to be in network with insurance companies. This is a necessity because most people in the United States have health insurance than ever before.  And it’s necessary because people today demand their healthcare physicians accept their insurance.  Honestly saying, if a physician is not in network with a patient’s health insurance plan, provider is at risk of losing that potential patient to a competing practice.

Medical Credentialing referred to as insurance credentialing or provider enrollment is the process of becoming affiliated with an insurance company so that physician can accept third party reimbursement. Enrollment applications can be +40 pages long, and to ensure smooth processing there’s a lot of necessary, time consuming, follow-up.

The process of getting on insurance panels can be challenging and lengthy.  It normally takes between 2-3 months to submit the necessary paperwork and correspond with insurance companies’ credentialing departments, before getting approved to join an insurance panel.  Because of the large amount of paperwork and correspondence required, medical providers generally find the process to be very time consuming.

Medicare, State Medicaid, Private/Commercial Payer Management

  • New Payer Contracts or Enrollments
  • Re-Credentialing or Revalidations
  • Changes of Information- Ownership or Acquired Locations
  • NPI Enumeration / Management
  • Set up of EDI, EFT, ERA, PECOS Processes or Provider Web Portals
  • Payer Issue Liaison / Resolution with Payers
  • Local, State, Federal Licensure Procurement

Why not choose a professional credentialing service provider like Bristol Healthcare Services to complete your provider enrollment process.