By Mick Raich, President
I’ve worked in the medical billing world for the past 20 years, both for billing companies and as the owner of an auditing firm. Never have I seen such rapid changes in the industry. Automation, outsourcing, and new workflow processes are driving these changes, with some billers struggling to keep up.
What can billing companies do to stay abreast of changes and shore up profit margins while retaining clients? Our new white paper looks at the current state of billing firms today, and then gazes through the looking glass at billing companies 10 years from now.
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Essentials for 2015 in Coding, Billing, and Collections for Clinical Labs and Pathology Groups
Thursday, December 4, 2014—Save the Date!
Are you prepared for the onslaught of coding, billing, and collection changes coming in 2015 relative to how Clinical Labs and Pathology Groups bill Medicare and private health insurers? Every lab that wants to do better at filing clean claims and getting faster payment must be prepared for these changes!
“It will be a high-stakes game in 2015 because both government and private payers are stacking the deck against clinical labs and pathology groups,” says Robert L. Michel, Editor-in-Chief of The Dark Report. “Across the nation, Medicare carriers and private health insurers are implementing myriad changes in coverage guidelines and reimbursement for both clinical lab tests and anatomic pathology services, in an effort to reduce their costs.
“There will be so many of these changes in how labs must code, bill, and collect during 2015 that, in a sense, the lab testing industry faces ‘financial death by a thousand cuts,’” continued Michel. “This makes it imperative that every lab’s billing and collections manager stay informed and be prepared for these changes.”
The good news: There’s still time to gear up for these changes! Get quickly up to speed on the specifics, and what you need to do to ensure fair and accurate payment in 2015 by taking advantage of this timely webinar, entitled “Essentials for 2015 in Coding, Billing, and Collections for Clinical Labs and Pathology Groups” on Thursday, December 4, 2014 at 1:00 PM EST.
Vice President of Commercialization Strategies, Consulting & Industry Affairs
President and Chief Operating Officer
APS Medical Billing
From the clinical lab side, we will tap the expertise of Rina Wolf from XIFIN. Rina is a nationally recognized expert in the field of laboratory reimbursement, and XIFIN is one of the nation’s largest companies providing revenue management and billing/collection services to labs.
For anatomic pathology practices, we’ll draw on the insights of Tom Scheanwald from APS Medical Billing, and Michelle Miller with Vachette Pathology, with decades of combined experience in compliant coding and effective billing for the pathology lab industry.
This panel of experts will present the essential changes coming in the clinical lab and anatomic pathology billing/coding/collection arena for 2015. They will discuss coming changes in Medicare, including the new final rules for the 2015 Medicare Physician fee update just published, as well as what is happening with private health insurers, ranging from UnitedHealthcare and Humana, to Blue Cross and Cigna, to name just a few.
What better or more timely forum for you to prepare your lab leadership and your billing/collection managers with the absolute most up-to-date information about how the Medicare program and private health insurers will change policies in 2015 policies that will make it even tougher for labs to submit claims and be paid on a timely basis.
Here’s just some of what you’ll learn during this
information-packed 90-minute webinar:
- Learn which Medicare program changes are likely to have the biggest impact on your Medicare billing and collections during 2015
- Understand the different ways that Medicare carriers will want your lab to submit claims during 2015, and how to best meet those requirements to ensure full and timely payment to your lab
- Know the specific new coding and billing requirements that will change at the nation’s largest health insurance companies during 2015
- Benefits of training your lab’s coding/billing/collections team in advance of January 1, 2015, to handle lab test claims in ways that meet the new Medicare and private payer requirements
- Discover overlooked secrets to generate a higher proportion of clean claims that payers reimburse at first submission
- How to reduce the average number of days that your lab’s claims go unpaid because your lab billing team is prepared for the changing requirements that take effect in 2015
- Gain insights into more requirements for lab test bundling by Medicare’s hospital outpatient prospective payment system (OPPS)
- Hear about specific changes in how payment for drug testing and pain management services will be handled during 2015
- Plus a live Q&A session to provide answers to your most pressing questions, and much more
THE DARK REPORT WEBINAR AT A GLANCE
DATE: Thursday, December 4, 2014
TIME: 1 PM EST; 12 Noon CST; 11 AM MST; 10 AM PST
PLACE: Your computer and/or speakerphone
COST: $195 per dial-in site (unlimited attendance per site) through 11/28/14, $245 thereafter
Vachette and Stark are committed to excellence, and part of that means education and continuous process improvement. Recently we sent some of our team to Effective Personal Productivity training. This entailed goal setting and time management. We received this testimonial from the leader:
“In my 30 years of leadership development and management training work, I’ve rarely come across a team whose members were so uniformly capable, articulate, hard-working, and purposeful while negotiating the challenging training experience we serve up to our clients.
For real success with this training (and, for us, that means not only improved business results, but also genuine behavior change), our participants have to make their training experience a top priority; their leaders have to give them strong support as they move through the learning process; and they have to apply their learning to real problems and opportunities and make things different and better.
Vachette / Stark gave us all that, and more. They created real synergy among themselves. Their combined learning effort brought about important organizational changes, changes that promise to help them stay in continuous improvement mode and to scale their company’s operations rapidly and effectively. It has been rewarding for me to be a part of these developments.”
— Bryce Harbaugh, Co-Owner, Midwest Management Systems, Toledo, OH.
I commend my team on a job well done; they will work hard to be diligent in using these new skills for both their own personal growth and the growth and management of our clients. I am lucky to have such strong, smart and caring people on my team.
By Jessica Jankowski, Executive Client Administrator
Once again we find another carrier creating a policy reflective of the Local Coverage Determination (LCD) that was published recently by WPS Medicare.
Medical Mutual of Ohio (MMO) created a policy effective July 2014 that tied the 88342 code to Lynch Syndrome tumor testing, thus requiring a prior authorization for any 88342 that comes through their door for processing.
While the 88342 is indeed one code that could be used in Lynch Syndrome testing, it is certainly not exclusive to this. Once these denials were detected, we promptly connected with a representative from MMO to review some of our claims, inclusive of pathology reports, so that they could see how these 88342 codes were being utilized.
Roughly a month later, they rescinded the policy. However, in order to get any claims paid, we needed to submit a “claims project” (fancy lingo for a spreadsheet with vital claim information) for MMO to reprocess the claims they originally denied. We were informed by MMO that this would be the only way to ensure payment on these claims (Medical Mutual , 2014).
1). Pay close attention to your denials. Is your biller providing you with detail of your denials monthly? This is a great way to spot any denial trends.
2). Be sure your biller can trace back all claims that were denied AND provide reporting on payment for these claims to ensure the process has been complete.
Medical Mutual (2014, June ). Retrieved July 2014, from Medcal Mutual Medical Policies: http://www.medmutual.com/provider/MedPolicies
Denials caused by missed update to the Skilled Nursing Facility (SNF) consolidated billing code edit lists
By Ann Lambrix
Executive Client Administrator
Yes folks, another issue with the G0461 and G0462 codes. Providers have seen denials for these codes stating “claim/service not covered by this payer/contractor. You must send the claim/service to the correct/payer contractor, indicating the charges should go through SNF consolidated billing.”
NOTE: Certain Healthcare Common Procedure Coding System (HCPCS) codes were not included in the 2014 annual update to the SNF consolidated billing code editing lists. A correction to the coding lists will be implemented in October, 2014. The affected HCPCS codes for practitioner billing are Q2050, (which will be added to File 1), and the professional component of G0461 and G0462 (which will be added to File 2). If you have claims with dates of service from January 1 through September 30, 2014, that have been erroneously denied, you should contact your Medicare Administrative Contractor to have the claims re-opened and re-processed.
Ann is the Executive Client Administrator at Vachette Pathology, your go-to source for auditing, practice management and industry updates and changes. Visit more of our news updates at vachettepathology.com/latest-news or call us at 517.486.4262.
It appears that Blue Cross Blue Shield of Georgia may be changing the rules without giving participating physicians fair advance notice.
The Medical Association of Georgia (MAG) has posted an article on its website alerting physicians that a new Blue Cross Blue Shield of Georgia (BCBSGA) provider agreement will automatically go into effect on November 15, 2014, replacing your existing agreement(s).
There is currently no indication of contractual changes on the BCBSGA website.
Our clients in Georgia have requested samples of the new contract(s) and fee schedule(s) for review, but there has been no response as of the printing of this letter.
MAG is indicating there are several points of concern, as the new contract(s):
- Does not require a signature to be effective, even if the physician/practice hasn’t received formal notification from BCBSGA;
- Allows BCBSGA to recoup money for claims that were incorrectly submitted by the physician/practice, offsetting payments without notifying the physician/practice beforehand;
- Allows BCBSGA to change its Procedure Manual by making a “good faith effort,” whereas a signature was required in the past;
- Removes a physician’s right to participate in a class action lawsuit against BCBSGA;
- Changes the clause on termination without cause, extending it to six months.
If you currently participate with BCBSGA, we encourage you to contact your BCBSGA representative and inquire if this new contract and fee schedule will apply to your practice.
If so, request full copies of both for review, and don’t hesitate to ask for more time to evaluate before it takes effect.
If you have questions, please feel free to contact Vachette Pathology at 866.407.0763. To keep updated on this and other current issues for pathologists, see our latest news or connect with me on LinkedIn.
Recently, WPS providers in Jurisdiction J5 and J8 began receiving denials of Medical Necessity on G codes submitted to Medicare for IHC stains performed on or after 8/1/2014. After further review, the culprit was identified…Local Coverage Determination (LCD) #L33219.
Labeled “Molecular Diagnostic Testing”, this LCD erroneously linked the G0461 and G0462 as medically necessary ONLY for the following three conditions: V16.0 (family history of malignant neoplasm of gastrointestinal tract), V84.04 (genetic susceptibility to other malignant neoplasm of endometrium), and V84.09 (genetic susceptibility to other malignant neoplasm).
WPS will be issuing a revision to the LCD that will be posted to its website by Oct 1, as well as reprocessing claims that were inappropriately denied since August 1. The mass reprocessing should take place around the end of September.
WPS Jurisdiction J5 and J8 is the Medicare Administrator for these following states: Iowa, Kansas, Missouri, Nebraska, Michigan, and Indiana.
Ann Lambrix is the Executive Client Administrator at Vachette Pathology, your go-to source for industry updates and changes. Visit our website for at www.vachettepathology.com or call us at 517.486.4262.
A recent billing audit we conducted for one of our clients led to a very serious finding that affects all pathology practices in Florida. We learned that several new 2014 CPT codes for immunohistochemistry stains (G0461, G0462 and 88343) are not listed on the 2014 Florida Medicaid fee schedule.
This is causing Florida Medicaid to erroneously deny claims when:
- A combination stain is billed to Medicaid.
- Florida Medicaid is secondary to Medicare or any other carrier that accepts G codes for IHC stains.
- G codes for IHC stains are billed to Florida Medicaid instead of using 88342.
These codes should be available for use as described in the 2014 CPT and HCPCS books:
88342 – Immunohistochemistry or immunocytochemistry, each separately identifiable antibody per block, cytologic preparation, or hematologic smear; first separately identifiable antibody per slide
88343 – Each additional separately identifiable antibody per slide (list separately in addition to code from primary procedure)
G0461 – Immunohistochemistry or immunocytochemistry, per specimen; first single or multiplex antibody stain
G0462 – Immunohistochemistry or immunocytochemistry, per specimen; each additional single or multiplex antibody stain (list separately in addition to code for primary procedure)
It is imperative that you audit claims for these codes and follow up on denials to ensure payment.
Vachette Pathology is an auditing and practice management firm working with practices in Florida and across the nation. We are not a billing service — we make sure billing is done right.
For further information, contact Mick Raich at 866-407-0763 or firstname.lastname@example.org. To keep updated on this and other current issues, read our latest news at VachettePathology.com or follow Mick Raich on LinkedIn.
Comparative Billing Report webinar on CBR201407 Immunohistochemistry and Special Stains hosted by eGlobalTech and Palmetto GBA
Angela Granlund, Executive Client Administrator, Vachette Pathology
On Wednesday, August 27, 2014, CMS contractors eGlobalTech and Palmetto GBA hosted a webinar on CBR201407, a recent comparative billing report on Immunohistochemistry and Special Stains. A team from Vachette Pathology attended, including myself, and have the following to offer in summary.
Five thousand rendering pathologists, identified by National Provider Identifier (NPI), were chosen for this CBR. Pathologists who did not receive this CBR did not meet the thresholds used to determine participation. These thresholds were not discussed or listed, however in the August G2 Compliance Advisor, the rationale given was simply because the participants’ billing patterns differed in some way from the national average of their peers.
The CBR focused on CPT codes 88305, 88312, 88313 and 88342, related specifically to esophageal and/or gastric biopsy specimens. Consultant cases were not included in this CBR.
The webinar began with a review of CPT coverage criteria: basics regarding policies of how and when to submit, medical necessity, billing protocols, etc.
The next topic covered was the methodology for determining the Average Allowed Charges per Episode of Care by CPT Code, the Average Allowed Services by CPT Code per Episode of Care, and the Percentage of Episodes with Special Stains.
- Average Allowed Charges per Episode of Care by CPT Code:
Determined by Total # Charges divided by Total # of Episodes for all CPT codes
- Average Allowed Services by CPT Code per Episode of Care:
Determined by Total # Services for single CPT code divided by Total # Episodes with that CPT code
- Percentage of Episodes with Special Stains:
Determined using the counts of Episodes with at least one special stain
Unfortunately the webinar included no visuals, as the link to the slides was not provided until after it ended. Provider results were discussed using random examples, yet the slides could not be seen.
The provider results fell into one of four categories: Significantly Higher, Higher, Does Not Exceed or N/A. The impression given, although not specifically stated, is that if you have codes with results that are Significantly Higher, that this is a “bad” thing.
In discussion with other attendees here in the Vachette office, we agreed this may not necessarily be so. There are at least two reasons providers may have higher results:
- All data is related to the individual NPI, so whether the provider works for a hospital-based group or an independent lab or both does not seem to be taken into consideration for the comparison to state or national averages.
- The results also do not seem to take into consideration if the provider works specifically with an endoscopy center and therefore may have higher results by default.
We also believe that this CBR is related to the article Palmetto GBA had on its website briefly which indicated that if you perform a high number of stains for gastric biopsies, then your practice would be looked at more closely. We feel they will use this data to target providers for audit.
Takeaways for providers: If you received a CBR, it is in your best interest to take the following steps:
- Review all coding policies for IHC stains
- Perform a coding audit on these types of cases to ensure they are indeed meeting these standards, and
- Continue to follow eGlobalTech (the CMS contractor) for any future lab-related reports
A recording of the webinar is available for download at the link below, along with additional data on this CBR:
Webinar Recording: http://www.cbrinfo.net/assets/cbr201407-webinar-recording.mp4
CBR website: http://www.cbrinfo.net/cbr201407.html
Statistical Debriefing: http://www.cbrinfo.net/cbr201407-statistical-debriefing.html
By Jessica Jankowski, Executive Client Administrator, Vachette Pathology
We all know or understand the basic idea of The Medicare National Correct Coding Initiative (NCCI), which establishes edits that are used to bundle service codes together. The basis for this is to outline certain billing codes that cannot be billed with other codes, indicating codes that further define some portion of the first code.
The modifier -59 has always been a go-to modifier to indicate a second service code is indeed distinctly different or separate from the first service code. Per CMS’ recent MLN Matters published January 2014, this modifier “can be broadly applied,” and CMS believes that some providers will use this modifier “to bypass NCCI,” thus allowing for abuse and “high levels of manual audit activity” (MLN Matters Articles, 2014).
CMS is correct in their statement. The -59 modifier has a broad realm for use, and can be used to identify different encounters, different anatomic sites, and distinct services. Per CMS, the -59 modifier is seldom used properly, and therefore CMS will bring into play four new modifiers that will further define or describe the -59 modifier. These will further be known as the –X modifiers (MLN Matters Articles, 2014). The modifiers and their descriptions are listed below:
- XE: Separate Encounter. A service that is distinct because it occurred during a separate encounter.
- XS: Separate Structure: A service that is distinct because it was performed on a separate organ/structure.
- XP: Separate Practitioner: A service that is distinct because it was performed by a different practitioner.
- XU: Unusual Non-Overlapping Service. The use of a service that is distinct because it does not overlap usual components of the main service.
According to the MLN Matters, these modifiers will be used in place of -59 when appropriate. Furthermore, CMS will still identify the -59 modifier when used; however, it is important to note that it is of great importance to use a more descriptive modifier when there is one available. We may even see CMS require these –X modifiers on specific CPTs that they feel are at a higher risk for incorrect modifier usage.
Bottom line: Understand these new modifiers and how they are used, and make sure your biller is aware of these and using them when appropriate.
MLN Matters Articles. (2014, 01). Retrieved 09 2014, from The Centers for Medicare and Medicaid Services : http://www.cms.gov/Medicare/Medicare.html