Many changes for 2006 promise to keep dermatologists and their billing staffs on their toes. While some changes won’t ensue until the year gets into full swing, others may have an immediate effect on practices as soon as implementation dates are in effect. No doubt, there will be many questions until everyone irons out the meanings of the new rules and regulations and how carriers will interpret them. I have a feeling that a lot of corrections and revisions will occur in the months to come. Here, I’ll review a few issues that are on the table and will need close monitoring.
Q: I understand that Medicare will reverse (and may already have by the time this issue is published) the 4.5% cut in Medicare reimbursements for FY 2006. I understand that the plan is to freeze the 2006 fee schedule using the same rates calculated for 2005. How do we deal with all the changes in reimbursements? Do we refile claims to get the money we lost in January? Do we have to refile secondary and then balance bill patients for $0.54? It all seems like one big mess. Any insight?
A: Assuming that Congress will rescind the 4.5% decrease and reinstate the 2005 fee schedule as the fee schedule for 2006 Medicare charges, here is what you should and shouldn’t do. According to the plan that Medicare will implement:
1. You won’t have to resubmit your 2006 Medicare claims to get full payment that you should have received for any services billed in January.
2. Medicare carriers will be allowed two business days after Congress passes the reversal to begin to “automatically reprocess claims” that already were paid under the 4.5% Conversion Factor cut (e.g., underpaid).
3. Carriers will have until July 2006 to reprocess those claims.
4. Any owed monies from the 4.5% cut period will be issued in one lump sum to practices rather than sending out small checks at various intervals.
5. Physicians will be offered a new 45-day enrollment period that begins upon enactment of the change.
6. Practices will be allowed to waive the increase in co-payments or deductibles for that period so that practices won’t have to balance bill patients for small dollar amounts.
Be sure you closely monitor your local carrier’s Web site for updates and instructions as carriers may vary instructions. I really don’t think this whole thing will be as messy as everyone says it will be, but I guess we will have to wait and see.
Q: I understand that there are a lot of significant changes in the criteria for billing consultations published by Medicare that were effective on Jan. 1, 2006. I have been told that these revisions could seriously affect how and when dermatologists could bill for these types of E/M visits. Can you enlighten me and tell me if you feel that these changes are as bad as rumors have it?
A: On Dec. 20, 2005, Medicare published Transmittal 788, Change Request 4215. This transmittal revised the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 30.6.10. It included the new CPT codes for 2006 for use for follow-up visits and second opinion evaluations beginning Jan. 1, 2006, due to the fact that the AMA CPT codes 99261 to 99263 (hospital inpatient follow-up consultations) and codes 99271 to 99275 (confirmatory consultations) were deleted.
The transmittal also addressed consultation policy clarifications regarding the definition of a consultation, documentation requirements, when and by whom a consultation may be performed/reported, what a split/shared evaluation and management service entailed, and non-physician practitioner rules regarding consultations. Consultation examples were also revised and updated.
Perhaps the most disturbing aspects of the newly revised consultation concern the following two instructions. (I’ll highlight the wording that concerns me and also many physicians.)
CMS states:
1. A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPPs (non-physician provider) plan of care in the patient’s medical record.
2. Consultation request: A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient’s medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP.
The reason for the consultation service shall be documented by the consultant (physician or qualified NPP) in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care. The consultation service request may be written on a physician order form by the requestor in a shared medical record.
3. A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition.
When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for this condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her service, in the patient’s medical record.
In a transfer of care, the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and the level of service performed and shall not report a consultation service.
These three issues are major reason for concern for the following reasons:
1. It requires formal communication between the requesting physician and the consulting physician. Merely having the patient write on the registration form the name of the referring doctor will no longer be acceptable. The new regulations require that the two physicians communicate verbally with one another or the requesting provider must forward a written request to the consulting physician.
2. If the requesting physician does not document the consultation request in his/her records, the criteria for a consultation are not met. Therefore, if an audit is performed for services charged by a consulting physician and they also request the chart note from the referring/requesting physician and no note of consultation request is documented in his/her chart notes, then the consultation will be recoded to an office visit or inpatient visit.
3. If the consulting physician takes over the total care of the condition for which the consult was requested (which is very common in dermatology practices), this is considered a transfer of care and a consultation service cannot be billed.
What is unclear to me is that the criteria state that the transfer of care is “arranged” between the two providers. What if no transfer of care is arranged and the consulting physician just continues to care for the condition? Can a consultation still be billed?
Expecting “After shocks”
The new regulations will certainly cause a serious outpour of concern and outrage from the medical community. I expect that there will be some strong “after shocks”. Keep monitoring Web sites and newsletters for updates.
Many changes for 2006 promise to keep dermatologists and their billing staffs on their toes. While some changes won’t ensue until the year gets into full swing, others may have an immediate effect on practices as soon as implementation dates are in effect. No doubt, there will be many questions until everyone irons out the meanings of the new rules and regulations and how carriers will interpret them. I have a feeling that a lot of corrections and revisions will occur in the months to come. Here, I’ll review a few issues that are on the table and will need close monitoring.
Q: I understand that Medicare will reverse (and may already have by the time this issue is published) the 4.5% cut in Medicare reimbursements for FY 2006. I understand that the plan is to freeze the 2006 fee schedule using the same rates calculated for 2005. How do we deal with all the changes in reimbursements? Do we refile claims to get the money we lost in January? Do we have to refile secondary and then balance bill patients for $0.54? It all seems like one big mess. Any insight?
A: Assuming that Congress will rescind the 4.5% decrease and reinstate the 2005 fee schedule as the fee schedule for 2006 Medicare charges, here is what you should and shouldn’t do. According to the plan that Medicare will implement:
1. You won’t have to resubmit your 2006 Medicare claims to get full payment that you should have received for any services billed in January.
2. Medicare carriers will be allowed two business days after Congress passes the reversal to begin to “automatically reprocess claims” that already were paid under the 4.5% Conversion Factor cut (e.g., underpaid).
3. Carriers will have until July 2006 to reprocess those claims.
4. Any owed monies from the 4.5% cut period will be issued in one lump sum to practices rather than sending out small checks at various intervals.
5. Physicians will be offered a new 45-day enrollment period that begins upon enactment of the change.
6. Practices will be allowed to waive the increase in co-payments or deductibles for that period so that practices won’t have to balance bill patients for small dollar amounts.
Be sure you closely monitor your local carrier’s Web site for updates and instructions as carriers may vary instructions. I really don’t think this whole thing will be as messy as everyone says it will be, but I guess we will have to wait and see.
Q: I understand that there are a lot of significant changes in the criteria for billing consultations published by Medicare that were effective on Jan. 1, 2006. I have been told that these revisions could seriously affect how and when dermatologists could bill for these types of E/M visits. Can you enlighten me and tell me if you feel that these changes are as bad as rumors have it?
A: On Dec. 20, 2005, Medicare published Transmittal 788, Change Request 4215. This transmittal revised the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 30.6.10. It included the new CPT codes for 2006 for use for follow-up visits and second opinion evaluations beginning Jan. 1, 2006, due to the fact that the AMA CPT codes 99261 to 99263 (hospital inpatient follow-up consultations) and codes 99271 to 99275 (confirmatory consultations) were deleted.
The transmittal also addressed consultation policy clarifications regarding the definition of a consultation, documentation requirements, when and by whom a consultation may be performed/reported, what a split/shared evaluation and management service entailed, and non-physician practitioner rules regarding consultations. Consultation examples were also revised and updated.
Perhaps the most disturbing aspects of the newly revised consultation concern the following two instructions. (I’ll highlight the wording that concerns me and also many physicians.)
CMS states:
1. A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPPs (non-physician provider) plan of care in the patient’s medical record.
2. Consultation request: A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient’s medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP.
The reason for the consultation service shall be documented by the consultant (physician or qualified NPP) in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care. The consultation service request may be written on a physician order form by the requestor in a shared medical record.
3. A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition.
When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for this condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her service, in the patient’s medical record.
In a transfer of care, the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and the level of service performed and shall not report a consultation service.
These three issues are major reason for concern for the following reasons:
1. It requires formal communication between the requesting physician and the consulting physician. Merely having the patient write on the registration form the name of the referring doctor will no longer be acceptable. The new regulations require that the two physicians communicate verbally with one another or the requesting provider must forward a written request to the consulting physician.
2. If the requesting physician does not document the consultation request in his/her records, the criteria for a consultation are not met. Therefore, if an audit is performed for services charged by a consulting physician and they also request the chart note from the referring/requesting physician and no note of consultation request is documented in his/her chart notes, then the consultation will be recoded to an office visit or inpatient visit.
3. If the consulting physician takes over the total care of the condition for which the consult was requested (which is very common in dermatology practices), this is considered a transfer of care and a consultation service cannot be billed.
What is unclear to me is that the criteria state that the transfer of care is “arranged” between the two providers. What if no transfer of care is arranged and the consulting physician just continues to care for the condition? Can a consultation still be billed?
Expecting “After shocks”
The new regulations will certainly cause a serious outpour of concern and outrage from the medical community. I expect that there will be some strong “after shocks”. Keep monitoring Web sites and newsletters for updates.
Many changes for 2006 promise to keep dermatologists and their billing staffs on their toes. While some changes won’t ensue until the year gets into full swing, others may have an immediate effect on practices as soon as implementation dates are in effect. No doubt, there will be many questions until everyone irons out the meanings of the new rules and regulations and how carriers will interpret them. I have a feeling that a lot of corrections and revisions will occur in the months to come. Here, I’ll review a few issues that are on the table and will need close monitoring.
Q: I understand that Medicare will reverse (and may already have by the time this issue is published) the 4.5% cut in Medicare reimbursements for FY 2006. I understand that the plan is to freeze the 2006 fee schedule using the same rates calculated for 2005. How do we deal with all the changes in reimbursements? Do we refile claims to get the money we lost in January? Do we have to refile secondary and then balance bill patients for $0.54? It all seems like one big mess. Any insight?
A: Assuming that Congress will rescind the 4.5% decrease and reinstate the 2005 fee schedule as the fee schedule for 2006 Medicare charges, here is what you should and shouldn’t do. According to the plan that Medicare will implement:
1. You won’t have to resubmit your 2006 Medicare claims to get full payment that you should have received for any services billed in January.
2. Medicare carriers will be allowed two business days after Congress passes the reversal to begin to “automatically reprocess claims” that already were paid under the 4.5% Conversion Factor cut (e.g., underpaid).
3. Carriers will have until July 2006 to reprocess those claims.
4. Any owed monies from the 4.5% cut period will be issued in one lump sum to practices rather than sending out small checks at various intervals.
5. Physicians will be offered a new 45-day enrollment period that begins upon enactment of the change.
6. Practices will be allowed to waive the increase in co-payments or deductibles for that period so that practices won’t have to balance bill patients for small dollar amounts.
Be sure you closely monitor your local carrier’s Web site for updates and instructions as carriers may vary instructions. I really don’t think this whole thing will be as messy as everyone says it will be, but I guess we will have to wait and see.
Q: I understand that there are a lot of significant changes in the criteria for billing consultations published by Medicare that were effective on Jan. 1, 2006. I have been told that these revisions could seriously affect how and when dermatologists could bill for these types of E/M visits. Can you enlighten me and tell me if you feel that these changes are as bad as rumors have it?
A: On Dec. 20, 2005, Medicare published Transmittal 788, Change Request 4215. This transmittal revised the Medicare Claims Processing Manual, Pub. 100-04, Chapter 12, Section 30.6.10. It included the new CPT codes for 2006 for use for follow-up visits and second opinion evaluations beginning Jan. 1, 2006, due to the fact that the AMA CPT codes 99261 to 99263 (hospital inpatient follow-up consultations) and codes 99271 to 99275 (confirmatory consultations) were deleted.
The transmittal also addressed consultation policy clarifications regarding the definition of a consultation, documentation requirements, when and by whom a consultation may be performed/reported, what a split/shared evaluation and management service entailed, and non-physician practitioner rules regarding consultations. Consultation examples were also revised and updated.
Perhaps the most disturbing aspects of the newly revised consultation concern the following two instructions. (I’ll highlight the wording that concerns me and also many physicians.)
CMS states:
1. A request for a consultation from an appropriate source and the need for consultation (i.e., the reason for a consultation service) shall be documented by the consultant in the patient’s medical record and included in the requesting physician or qualified NPPs (non-physician provider) plan of care in the patient’s medical record.
2. Consultation request: A written request for a consultation from an appropriate source and the need for a consultation must be documented in the patient’s medical record. The initial request may be a verbal interaction between the requesting physician and the consulting physician; however, the verbal conversation shall be documented in the patient’s medical record, indicating a request for a consultation service was made by the requesting physician or qualified NPP.
The reason for the consultation service shall be documented by the consultant (physician or qualified NPP) in the patient’s medical record and included in the requesting physician or qualified NPP’s plan of care. The consultation service request may be written on a physician order form by the requestor in a shared medical record.
3. A transfer of care occurs when a physician or qualified NPP requests that another physician or qualified NPP take over the responsibility for managing the patient’s complete care for the condition and does not expect to continue treating or caring for the patient for that condition.
When this transfer is arranged, the requesting physician or qualified NPP is not asking for an opinion or advice to personally treat this patient and is not expecting to continue treating the patient for this condition. The receiving physician or qualified NPP shall document this transfer of the patient’s care, to his/her service, in the patient’s medical record.
In a transfer of care, the receiving physician or qualified NPP would report the appropriate new or established patient visit code according to the place of service and the level of service performed and shall not report a consultation service.
These three issues are major reason for concern for the following reasons:
1. It requires formal communication between the requesting physician and the consulting physician. Merely having the patient write on the registration form the name of the referring doctor will no longer be acceptable. The new regulations require that the two physicians communicate verbally with one another or the requesting provider must forward a written request to the consulting physician.
2. If the requesting physician does not document the consultation request in his/her records, the criteria for a consultation are not met. Therefore, if an audit is performed for services charged by a consulting physician and they also request the chart note from the referring/requesting physician and no note of consultation request is documented in his/her chart notes, then the consultation will be recoded to an office visit or inpatient visit.
3. If the consulting physician takes over the total care of the condition for which the consult was requested (which is very common in dermatology practices), this is considered a transfer of care and a consultation service cannot be billed.
What is unclear to me is that the criteria state that the transfer of care is “arranged” between the two providers. What if no transfer of care is arranged and the consulting physician just continues to care for the condition? Can a consultation still be billed?
Expecting “After shocks”
The new regulations will certainly cause a serious outpour of concern and outrage from the medical community. I expect that there will be some strong “after shocks”. Keep monitoring Web sites and newsletters for updates.
