Medicare & Medicaid: The Tricks of the Trade

NEWS AND UPDATES

On February 29, 2008, the Centers for Medicare and Medicaid Services(CMS) issued an Update to Audiology Policies. This document outlines the policies related to billing audiological services to Medicare. Per CMS, Medicare Audiology Policies have not been updated since 2003. The goal of this document is to clarify the language contained within the existing Medicare policy, as well as to add new guidelines to the policy. One significant change in policy is that Audiologists are to bill under their own National Provider Identifier (NPI) and not under the NPI of a physician. The Update to Audiology Policies becomes effective on April 1, 2008 (with an implementation date of October 1, 2008). ADA strongly encourages all of its members to read the entire document.

» CMS Update to Audiology Policies, April 1, 2008

The following summary document highlights the key points in the Update to Audiology Policies (See CMS Manual System, Pub 100-02 Medicare Benefit Policy, Transmittal 84, February 29, 2008):

» Summary of Update to Audiology Policies

TIPS FOR FILING MEDICARE & MEDICAID CLAIMS

The following tips for filing Medicare & Medicaid claims are designed to help busy practitioners navigate through the Medicare system with fewer denials and greater ease:

• Obtain a written referral from a physician. While the referral does not technically have to be in writing, it is strongly recommended in the event of an audit. [A physician referral is required to bill the claim to Medicare because audiologists currently do not have direct access.] You must have a separate referral for each incident or episode of care. The physician’s name and NPI must be on your claim. If you do not have a referral, the patient must sign an Advanced Beneficiary Notice and they must understand that they will be responsible for all charges incurred.
• Make copies of your patient’s insurance cards; you may need the information the card supplies after the patient leaves your office.
• Develop and use a Fee Bill (Superbill). Claims are most often denied because of a coding error; use of a Superbill minimizes errors.

» View Sample Superbill

• Read the Information on the Advanced Beneficiary Notice (ABN) and review the attached combined ABN/Notice of Exclusion of Medicare Benefits (NEMB) form. Use it in accordance with the outlined instructions. Patients should read and sign an ABN prior to having services rendered. Inform Medicare that you have obtained a signed ABN and add the –GA modifier to the claim next to those procedures outlined on the ABN. The new ABN allows you to collect payment at the time of the visit and to refund the patient if Medicare pays for the procedure(s) outlined on the form. When this form is used as an NEMB, always have the patient choose Option #2.

» Download Advance Beneficiary Notice and Instructions (PDF)

• “Routine” hearing evaluations are not a covered Medicare benefit; the patient should sign a Notice of Exclusion from Medicare and should be billed for any procedures; if they must be billed to Medicare (so that you can receive a denial to submit to the secondary carrier), have the patient sign an Advanced Beneficiary Notice and add the GY modifier to the claim.
• Do not charge different amounts to different patients or insurance companies; create one, standard fee for every service, procedure, and product and charge that same fee to every patient or insurance carrier, regardless of whether you expect payment or not. (Some of these charges will be non-covered by the insurance company and, thus, will be written off).
• Patient information sheets should include HIPAA Notice of Privacy Practices Acknowledgement.
• If the patient has a secondary insurance to Medicare, they typically only cover those services that Medicare covers; exceptions may apply for some Medicare HMOs.
• Request co-payments or deductible payments at the time of visit, especially in January through March, when deductibles may not have been met; it costs money to bill the patient. (AMA statistics show the average cost for in-practice claims filing is $11.50 to $18.00 per claim.)
• Request private pay billing by the patient for services such as Canalith Repositioning and Tinnitus Retraining Therapy as there are currently no CPT codes specific to these procedures. Billing and reimbursement are difficult for these procedures, especially in private practice and especially when billing Medicare. The use of 92700 to bill these procedures is inconsistent and not recommended. S9092 (Canalith Repositioning, per visit) is a temporary HCPCS code that can be used with some private insurance carriers to bill Canalith Repositioning. This S-code is not recognized by Medicare.
• Do not bill hearing aids to Medicare unless the patient’s secondary requests a formal denial. After denial, submit with the –GY modifier (“Item or service statutorily excluded or does not meet the definition of any medical benefit”)
• You cannot bill for cerumen removal on the same day as a physician visit or on the same day as most audiologic procedures and expect to receive payment; it is inclusive to the testing (CMS Regulations & Guidance). If you work with a physician, you can use G0268 (Removal of impacted cerumen, one or both ears, by physician on same date of service as audiologic function testing) and will possibly receive payment (it is at the discretion of the insurance carrier). If you are an independent audiologist in private practice, you will not receive reimbursement from Medicare for cerumen removal; as a result, request private pay billing by the patient for the cerumen removal. Inform the patient that the cerumen removal may be paid for by insurance if the patient were to make an appointment and have it removed by a physician.
• Never advertise free hearing tests if you are a Medicare or Medicaid provider! You cannot give it free to one group and then charge another's insurance. This is fraudulent practice.
• Do not charge different amounts for different patients or insurance companies; create one standard fee for every procedure, service and product and charge that fee to every patient or insurance carrier.
• Do not unbundle service to try to increase reimbursement; you will get denied.
• Do not bank on the fact that Medicare will always cover the hearing evaluation; you can only ensure coverage of the initial test per each recipient’s lifetime.
• Realize (and help your patients accept) that insurance does not pay for 100% of anything they want!
• Create a formula for calculating your diagnostic and rehabilitative procedure fees based upon the Medicare Relative Value Units. This information can be obtained from numerous reimbursement manuals available from Medical Arts Press and Ingenix, from the Federal Register from the first Monday in November (can be purchased for $10 from the US Government Printing Office at 202-512-1800). Medicare and Medicaid base their payment upon Medicare Relative Value Units.
• Obtain a current copy of the CPT, ICD9, and HCPCS manuals.These may be purchased from:
  
» American Medical Association
» Medical Arts Press
» Ingenix Online


• Purchase office management/billing software or obtain free or low cost billing software from your Medicare intermediary so your practice can submit claims electronically.
• Be careful when entering into contractual relationships with other healthcare providers, especially physicians, as you could be violating Stark laws; there can be no referral incentives, kickbacks, etc. provided. If you are unsure about a relationship you are involved in, consult an attorney.
• Determine the Medicare coverage specifics for your State or Medicare contractor. Each Medicare Contractor has the right to create coverage guidelines for issues where Medicare regulations are vague or lacking.

» Check Local Coverage Determination

• Keep abreast of the latest information:
  
» The Centers for Medicare and Medicaid Services
This site has links to provider services for Medicare and Medicaid. It includes information regarding enrollment, fee schedules, contact numbers, etc.

» Health and Human Services
This site also has basic information and links regarding the Medicare and Medicaid programs.

SPECIFIC LINKS WITHIN EACH SITE:

» CMS: Quarterly Provider Update
» U.S. Dept of Health and Human Services: Policies & Regulations

ADDITIONAL MEDICARE & MEDICAID RESOURCES

» Medicare Provider Enrollment Information
» Medicaid Contact Information
» Medicare Physician Fee Schedule
» Local Coverage Determination

This will help you locate local billing guidance and rules required by your local fiscal intermediaries or Medicare payers. These rules can be very specific so it is important to keep abreast of these guidelines

If you have any specific questions, visit the reimbursement forum or send an e-mail to the ADA Help Desk.

DISCLAIMER: The foregoing information is provided as a resource for our members. It is not intended and should not be construed as an endorsement of any of the vendors or their products or services; as such, ADA makes no warranty whatsoever, either express or implied, including the warranties of merchantability and fitness for a particular purpose regarding any of the products listed above and makes no recommendation as to the accuracy or suitability of the information for your particular situation. ADA members are encouraged to seek legal counsel to ensure compliance and are responsible for their own knowledge of both federal and state policies as it pertains to HIPAA. Neither ADA, nor any of its officers, directors, agents, employees, committee members or other representatives shall have any liability for any claim, whether founded or unfounded, of any kind whatsoever, including, but not limited to, any claim for costs and legal fees, arising from the use of these opinions.