Radiology, Cardiology and other procedure codes may have both a professional and technical component. Determining the correct POS code determines whether to bill a global code, a professional only code, a technical only code or a global code with modifier.

Place of service codes determine payment rates.

Medicare uses a resource-based relative value unit (RVU) to determine the reimbursement for physician practice expenses. This reflects the difference in a physician's practice expense for services performed in a facility as opposed to other settings, such as an office. Procedures subject to the facility-based payment reduction are identified with a "#" sign on the Medicare Fee Schedule which may be found on the WPS Website.

Certain services provided in the physician s office will be reimbursed at a higher reimbursement rate based on the greater expenses incurred. This includes personnel and utility costs in addition to the cost for the office itself.

Place of service codes determine whether the provider can bill Medicare Part B for their services.

Medicare Part B is not billed for certain non-physician practitioner services rendered in a facility. These include inpatient or outpatient hospital, skilled nursing facility, and ambulatory surgical centers in addition to others. Examples include physical therapy services rendered by a physical therapist in the skilled nursing facility or services rendered as incident to in the outpatient department of the hospital. The facility includes these non-physician practitioner services in their charges when submitting to the Fiscal Intermediary.

Providers are encouraged to evaluate their internal billing systems to verify they are choosing the correct POS codes when submitting claims to Medicare.

Starting May 23, 2005, all health care providers can apply for their National Provider Identifier (NPI). The NPI will replace health care provider identifiers in use today in standard health care transactions. The health plans with whom you do business will instruct you as to when you may begin using the NPI in standard transactions. All HIPAA covered entities except small health plans must begin using the NPI on May 23, 2007; small health plans have until May 23, 2008. For additional information, and to complete an application, visit https://nppes.cms.hhs.gov on the web.

Also, an instructional web tool, called the NPI Viewlet, is now available for viewing at http://www.cms.hhs.gov/medlearn/npi/npiviewlet.asp and under "HIPAA Latest News" at www.cms.hhs.gov/hipaa/hipaa2 on the CMS website. This tool provides an overview of the NPI, a walkthrough of the application, as well as live links to the NPPES website where the learner can apply for an NPI. This tool is designed for all health care providers. In the near future, you will also be able to access the viewlet at https://nppes.cms.hhs.gov on the web.

Read the operative report before you append modifier -22 to a procedure code. Specificity in the documentation is often the decisive factor in getting the -22 modifier paid. The picture you paint should make it very clear why the circumstances were unusual and what you did that was outside the normal circumstances for you.

Always send a cover letter along with your operative notes. The letter should be short, simple, and to the point. The insurance company's reviewer may be a non-clinical person and this person must be able to understand why the case deserves more money.

Use the cover letter to compare typical circumstances with the difficulty encountered in the current case. For example, a surgery may normally last about 3 hours, but in a particular case it took an additional 1-1/2 hours due to the severe intra-abdominal adhesions. There was extensive lysing of those adhesions before surgeons got to the tumor. State this in your cover letter and operative notes.

Make sure your operative notes document the difficulty encountered as specifically as possible. This is often the biggest obstacle to getting the -22 modifier paid. Doctors will sometimes fall into the trap of cookie-cutter operative notes. That means that even if the coder knows the patient was difficult, the operative note doesn't look any different than any other operative note.

Propose a fair fee increase in your cover letter, using your explanation of the case as the rationale. If you feel you performed 30% more work than indicated by the code used, then increase your fee by 30%.

This year's Summit is filled with information that will help you lead your practice to higher profitability and efficiency for 2006. All instructional materials and lectures at the 2005 Medical Practice Coding and Compliance Summit are geared specifically for medical office staff and private practice physicians. You will get all the latest coding and Medicare updates, tips on risk management, financial and budgeting tools, and much more. You will have the opportunity to attend three general sessions and choose from 14 breakout sessions.

Both physicians and staff will come away from this summit with valuable tools and tips aimed at improving revenue and safeguarding the practice against costly risks. Participants will learn how to optimize productivity, guard the practice against an audit, and navigate complex compliance issues.

Register early

Participants who register before August 31, can save $100 off the registration fee for this program (regularly $695). To register, call 800-259-5562, or go to the Summit Web site: www.thecmcgroup.net/2005summit.html.

Mail-in and fax registrations are also accepted - you can complete a registration form by printing out the form located on the Web site.

Accommodations

We have reserved a limited number of rooms at a discounted rate at The Imperial Palace Hotel and Casino. The rates are as follows: $69/night for a deluxe room, $129/night for a king suite. Rates are good Nov. 8, 9, and 10. For guests who wish to stay through Friday and Saturday nights, the rates increase to $89 and $129 per night, respectively. Please reserve your room(s) well in advance to ensure availability. Call 800-800-2981. To obtain the discounted group rate, mention "the CMC Group room rate." Guest room assignments will be made by the hotel based on availability. Reservations must be guaranteed with a major credit card or a deposit equal to one night's room and tax.

To request a brochure, log in to the Web site noted above and click the brochure request button, or call 800-259-5562, ext. 229.

In many regions of the country a medical practice that did not sign up with managed care plans when they first appeared in the area are now facing what is commonly called "a closed panel". This means that the plan has contracted with a limited number of providers and is no longer accepting applications or credentialing new providers. A plan may have a variety of reasons support the decision to limit the number of providers. It may be to insure adequate patient load for the paneled providers to offset the discounted fee schedule. In other words the more providers on the plan the less volume of patients to providers. The plan may even say that it is for quality control. For whatever reason the plan gives, a provider may now find himself/herself on the outside looking in. (Of course if you are on the inside, you may have a totally different observation on this subject.)

If this has happened to you, don't feel that you do not have any options. Your best offense is a defense. You must initiate a battle plan. It can happen, you can crack the panel. You must sell yourself and the practice. Approach this challenge as if you were seeking employment. (You are!) You should be creative and utilize every avenue to entice the plan.

Compiling this information into a concise, well written marketing package will introduce your practice and demonstrate how valuable of an asset you would be to the plan. The steps to take are:

Of course it goes without saying that you must have done other homework. You have to know your practice statistics and overhead. You also must know the managed care lingo. Stop loss, capitation, withholds, indemnification, hold harmless, utilization management are just a few of those important contact areas in which you must have knowledge.

Once you have your marketing plan ready, make your contacts. Go up the chain of command. The plan provider representative, the medical director, and plan administrator/ Sell the plan on your practice. Now, after all of this you still may not be placed on the panel but don't give up. Call every couple of months. Inquire if the plan will be accepting applications in the next few months.

Ask under what circumstances are they accepting applications. You should also watch the business section in the newspaper as many times there may be a very very small notice in the business section of the Sunday newspaper that the plan is accepting applications. That may be the only advertisement that the plan will be accepting applications. The plan may be open for only a two to four week time frame.

In closing remember this. The more in-depth concentration of managed care in your area, the more likely you will be to have closed panels. You should never put you decision on whether to join a plan on the back burner. You very well may miss out. In many instances plans will have a limited time initial provider enrollment. If for some reason you can't make the decision right away, contact the plan. See how long enrollment will be open. Don't set yourself up to be "on the outside looking in".

© 2005 Practice Management Institute. The Link is a monthly newsletter distributed by Practice Management Institute. All other rights reserved. None of this material may be reprinted without the expressed written permission of Practice Management Institute. For reprint permission, please contact PMI's Marketing Communications Department at:info@pmiMD.com. We encourage you to forward The Link, to your colleagues, provided this copyright notice remains part of your transmission.

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Advice given is general, and readers should consult professional counsel for specific legal, ethical, or clinical questions. Users of this service should consult an attorney familiar with federal and state health laws.