| This page is loaded with actual current coding questions received by our office. We thought it would be helpful information to pass along. |
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Questions Regarding OPTing-out of the Medicare Program:
Q: The rules state that a NP/PA MUST bill their services as a PAR provider, can they operate as an OPT-out Provider?
A: Yes. The rule that states that they must be a PAR provider does NOT relate to the opt-out provider status. This rule is actually stated only as it applies to their services being performed as PAR vs. Non-PAR status.
Q: Since Medicare does not cover the new telephone services and internet service codes, how can we bill patients for this service?
A: Medicare has a form called the NEMB form. This form is used whenever we know the service will NEVER be covered by Medicare. We can get a signed NEMB form for this service and bill the patient directly. We do recommend that your practice also have a waiver in addition to the NEMB form. The NEMB form can be found on the FREE FORMS link (or by clicking FREE FORMS here).
Q: How do we know when to use Ophthalmology service codes or E&M service codes in our eye practice?
A: Ophthalmology services may be billed using either the ophthalmology specific codes or the E&M service codes. However, CPT guidelines do state when each service should be billed, and this has been concurred through the AAO.
Intermediate Services should be billed when there is a complication to either a new or established problem.
Comprehensive Services should be billed when there is a diagnostic or therapeutic plan of care established for a patient.
All other services that do not fit these two descriptors should be billed with E&M services.
This is actually a good thing. While the documentation guidelines are more stringent for E&M services, the reimbursement is significantly higher.
Most patients presenting to an ophthalmology practice will be a consult as they are typically sent by a physician requesting an opinion from the ophthalmologist. Using this as our guide, and the 2007 physician fee schedule, compare the following reimbursements:
Ophthalmology
Services |
Medicare Rate |
E&M Consultation Service |
Medicare Rate |
| 92002 |
$70.86 |
99241 |
$50.78 |
| 92004 |
$128.09 |
99242 |
$94.36 |
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99243 |
$129.61 |
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99244 |
$191.00 |
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99245 |
$237.23 |
Billing according to the CPT guidelines for these services may actually increase your bottom line based on the above reimbursement module.
If you would like more information on this billing strategy, please contact our office.
Q: What is a split/shared visit according to CMS guidelines?
A: A split/shared visit according CMS guidelines is a visit in which one or more individuals participate in the encounter with the patient- BUT we are NOT talking about a scribe here.
A scribe merely "transcribes" the actions that take place between the provider and the patient.
An example of a split/shared encounter would be one in which the NP gathers the history information and performs the exam, then the physician comes in and reviews the history with the patient- reinitiates the problem pertinent areas of the exam and formulates a plan of care.
In this example both the physician and the NP played a role in the completing the patient encounter on this date of service.
As a reminder, Consultation services can NEVER be billed as a split/shared service- meaning a consult can NEVER be incident-to. |
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