Tuesday, August 29, 2006
No loopholes for billing on vaccines for non-established Medicare patients
Q.
Due to the flu vaccine shortage, we have decided to vaccinate our regular patients. We would like non-established Medicare patients to pay the regular fee for vaccines rather than Medicare's fee. Is this allowed if non-patients sign a private agreement?
A.
No, this is definitely not permitted. If you see a patient with Medicare Part B coverage, you have to accept assignment on the vaccine and administration. This is not negotiable as the injections must be filed with Medicare and private agreements with the patient do not change the requirement.
Q.
The Emergency Department summoned me for a consult for a critically ill patient. During the consult, I treated the patient with several procedures (insert CV catheter and arterial catheter). The patient expired during my visit. I documented "Critical care time 1 hour, 40 minutes; total time 2 hours, 40 minutes," so that I can bill the out-patient consult (99245) and critical care (NEED CODE HERE). My staff says I cannot bill for both. Who is right?
A.
Your staff is doing you more than one favor by saying you cannot bill for both codes during the same encounter. Not only are they informing you of the correct coding, but they may be making you money. It appears that the entire time you were working on the patient, the patient was critical. If this is the case, you should properly bill one charge of 99291 (30-74 minutes) and then two charges of 99291 for the additional 30 minutes each.
Q.
We do not provide primary care in our geriatric consult service, which includes an outpatient clinic, inpatient consult service, and several geriatric rehab units. Patients come for an initial consultation, which lasts 2 to 3 hours. After that visit the team (physician, social worker, and nurse practitioner) discusses the patient. Within 4 weeks, the patient returns for an hour-long visit to review any findings and to receive recommendations. Both visits are recorded; results are forwarded to the physician who initiated the consult. Is the second visit considered a follow-up consult or an established patient follow-up? If the patient needs a medication change, are our physicians allowed to make the change, or do they have to recommend it to the PCP?
A.
The second visit, in which the patient receives the team's results, cannot qualify as a follow-up consult, because such consults are in-patient, and this appears to be an out-patient service. Therefore, the second visit will be an established patient office visit (99211- 99215).
Yes, your physician can write a prescription, order medications, initiate treatment, etc. In fact, your physician can conduct any of these procedures on the first visit, since initiation of treatment does not negate the consult.
Q.
What are the guidelines for billing a new patient if a provider was previously employed by a provider group and services were billed under the group's tax and billing ID numbers, but now the provider is solo and wishes to bill patients previously seen (within 3 years) as new patients, under his own tax and billing ID, since he has to make new patient charts.
A.
Medicare considers those patients established, since the physician has provided professional care, in any setting, to those patients within the previous 3 years. The need for creating a new chart is not a factor in reimbursement.
Don Self is an expert in Medicare coding and has been educating health professionals for 14 years through consultations and seminars. Send Medicare-related questions to Don Self c/o Geriatrics, 7500 Old Oak Blvd., Cleveland, OH 44130 (toll-free fax 800-788-7188, e-mail donself@donself.com). All questions will receive a personal answer, and some will be published. No fee is charged for single questions; a consultation fee may be charged for multiple questions. Access to related information is available on the web at: http://www.donself.com. The information in this column is designed to be authoritative. The publisher is not engaged in rendering medical or legal advice.
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