Q&A: Mixing provider types, protocols and payer behavior

Q1. I have a question about Medicare new versus established patients. In the following scenario: A patient is seen in our ER, treated and released and at a later date (within 3 years) is seen by one of our providers who is also credentialed as an ER physician in our clinic for wound care (realizing that wound care is not considered a specialty under Medicare guidelines) as a wound care specialist –would the patient be considered established since the provider is credentialed in Emergency Medicine?

A1. If it was the same MD that treated the pt. in the ER, then saw them within 3 years in your clinic - the second visit is established.

You say, 'also credentialed as ER', meaning he/she has other credentials?

This gets to be about which taxonomy code is used for the provider on the second encounter. If it's ER, they might deny it.

Q2. Patient is seen in the hospital or as a new patient in the office under the mid-level. We bill the hospital initial visit or office new patient under the mid-level only, so without supervisor (not incident to)

Mid-level meets with their supervising provider and comes up with a plan of care for the patient.

Patient has a follow up visit with the mid-level. Patient still has never seen the provider, but he/she did create plan of care. Can this follow up visit be billed “incident to”?

A2. This case might play out somewhat differently across a variety of payers or Medicare contractors, but most would probably determine that the patient needs to have been initially seen by a physician who is a member of the group and also developed a plan of care. So it's not just the plan of care, they need to have 'seen' the Physician....

The payer may or may not spell this out directly.

Q3. Thank you for your excellent articles on coding in Physicians Practice. One problem that recurs in my practice, is that when my billing clerk tries to determine what the codes will be for telepsychiatry, video + voice, they all (except United Health) give her the same reply: “We can’t advise you as to how to bill….” No matter how often she reiterates that all she wants to know are the modifiers, not how to bill, they still say, “We can’t advise you…” They refer us to their websites, which are poorly designed and Byzantine at best. Every insurance carrier seems to have different codes/modifiers, and so she files them and can only hope for the best. Any suggestions will be gratefully accepted!

A3. That's very kind of you to say!

But I'm not sure I can do much for you re your question. The payers drill it into their service reps’ and provider reps’ heads that they can't 'tell you how to code' - as you have clearly experienced on your own. This stems from a fear that they would be giving you 'the formula' to payments that might bypass any relevant claims processing edits.

United used to claim that they didn't even know what was covered at any given moment - said 'it changed too fast and they had too many plan types etc.' - they actually said in court that the only way you could determine their payment policies was by reading your EOB's - and whatever they did or didn't pay you was a reflection of their payment policy.

To them, the modifiers in particular are the keys to the kingdom... they are designed to 'turn off' edits and get you to payment. So they want you to use the coding tools, i.e. CPT, HCPCS and all the bits to make your claim.

_{About the Author}

_{Bill Dacey, MHA, MBA, CPC-I is principal in The Dacey Group, Inc., a consulting firm dedicated to coding, documentation and compliance concerns for physicians. Bill is an evaluation and management (E/M) coding expert and has been active in physician training for more than 25 years. He can be reached at} billdacey@msn.com.