Part B News | Ask a Part B News Expert

Directory glitch caused patient overcharge? Under NSA, you pay, not the plan

08/08/2022

Question: I know the No Surprises Act (NSA) and the CMS rules that put it in practice require that provider directories be kept up to date. But I thought that was all the insurers’ responsibility. The other day I was looking at guidance from a CMS’ Center for Consumer Information & Insurance Oversight (CCIIO) that says, among other things, “Under the No Surprises Act, providers and health care facilities must generally ... refund enrollees amounts paid in excess of in-network cost-sharing amounts with interest, if the enrollee has inadvertently received out-of-network care due to inaccurate provider directory information.” Why is this the providers’ responsibility?

Admit service dogs within reason, but ‘emotional support’ doesn’t fly

06/06/2022

by: Roy Edroso

Question: I have read the Part B News story about service animals in the practice (PBN 4/9/18). Since that story was published, I have seen a lot of coverage of “emotional support” animals and wonder if shared public spaces like the doctor’s office are required to accommodate them as well.

Ensure appropriate documentation for modifier 25

06/06/2022

by: Sarah Gould, CPC

Question: What is the best way to determine if an E/M service is above and beyond the physician work normally associated with a procedure to justify the use of modifier 25 (Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service)?

Refer to AMA guidelines, not Medicare, for approved RTM billing

05/23/2022

by: Laura Evans CPC

Question: We have a provider who is performing knee implants that will allow him to bill for the remote therapeutic monitoring (RTM) codes (98980 and 98981). The vendor is telling us that clinical staff can perform these services based on coding information they found online, but a recent CPT Assistant seems to be saying that a physician or qualified health care practitioner (QHP) must personally perform those services and that they can’t be billed by clinical staff. I am not sure how to proceed.

No time limit on incident-to billing if problems are unchanged

05/09/2022

by: Richard Scott

Question: I read your recent article about incident-to billing. One of my practitioners has a question I am unable to answer. Is there a time limit on what is considered a new problem? For example, if a patient is not treated for a particular problem in over a year, is it now considered a new problem? Please advise.

Didn’t get discharge data? Sorry, you can’t charge TCM

05/02/2022

by: Roy Edroso

Question: We performed transitional care management (TCM) on a patient who had been discharged as an inpatient by a provider from a different practice. When our claim went in, the payer did not have the discharge summary on file and denied our claim. What can we do?

Turn to Q codes, modifier JW for discarded CTP products

05/02/2022

by: Sarah Gould, CPC

Question: How do you code and bill for wound debridement involving the disposal of unused cellular-based tissue product (CTP)?

Time is on your side when documentation doesn’t support MDM

04/11/2022

by: Julia Kyles, CPC

Question: Under the new E/M office visit guidelines, is there a way to code an office visit when the note doesn’t contain enough information for medical decision-making (MDM)? We regularly see charts that say things like “nosebleed” or “reviewed labs.” Asking providers to update their notes doesn’t work.

Stick to Medicare’s guidelines if you revise the ABN

04/11/2022

by: Julia Kyles, CPC

Question: Our practice is looking for ways to reduce the number of documents we use. Are we allowed to create our own version of Medicare’s advance beneficiary notice of non-coverage (ABN) that is based on a financial waiver used by some of our private payers?

Resist the temptation to use Medicare’s risk examples for office visits

03/21/2022

by: Julia Kyles, CPC

Question: The CPT guidelines for E/M office visits (99202-99215) do not include examples of tests or treatments that are low risk or minimal risk. Our coders aren’t sure how to score risk for some encounters, so they send questions to the providers, which has had a negative impact on everyone’s productivity. Can we continue to use the examples of low and minimal risk management options from Medicare’s table of risk to code our office visits?

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