Q.
I have one payer (UnitedHealthcare) who consistently won’t pay for an office visit and Pap on the same date of service. Ladies do not want to have to come back on a different day for me to address their hypertension or allergies or whatever. I’ve not seen a written policy on this from United. Any ideas?
A. A quick search of UnitedHealthcareOnline.com brought up its policy, which is not to pay for a problem-focused visit and Pap done during the same visit. So my first advice is, at the very least, to take advantage of the information payers do make available to you so you are clear what is covered.
Also, I assume that women don’t come in solely for a Pap, but also for a preventive care visit that includes the Pap. Look into coding for a full preventive exam, assuming you are doing that, instead of just the Pap.
NO REQUIREMENT TO OFFER BENEFITS
Q. I am thinking about opening my own practice. If I have only three or four employees, am I legally required to set up a retirement plan for them? Also, in the same situation, do I need to provide them with a health insurance plan, or could I pay them a higher salary and have them get their own health benefits?
A. State rules may vary a bit, but generally, no, you are not required to offer health benefits or a retirement plan. Of course, you might have a hard time recruiting if everyone else in your area offers these benefits.
Some physicians use a PEO — professional employer organization — to manage such issues. A PEO will find, retain, and manage your staff, and because they have lots of employees in addition to yours, they can get good rates on benefits. Of course you have to pay them, but it might be worth it. Just Google “PEO” in your part of the world. Also, note that I recently wrote a Bigger Picture column on some pros and cons of PEOs; read “No More HR Headaches” at PhysiciansPractice.com.
CLIA BILLING DETAILS
Q. I enjoy your newsletter (Pearls on Coding, sign up at PhysiciansPractice.com) on coding and the article on CLIA was very informative until I got to the last statement. It said that we learn from the mistakes we make. Well, I certainly learned from mine: I added the –QW modifier to a lab test that was CLIA-waived but did not have the –QW listed on the CLIA list. If you double-check the CLIA list, some CPT codes have –QW and some do not. Those that do not have the –QW do not require it when filing. We received denials for invalid modifier and I was required to remove the –QW to those codes I had previously added. I thought that if a lab test was waived it required the –QW.
A. Answer provided by Betsy Nicoletti, certified professional coder:
That’s right, generally, but there is a qualification. Many tests, such as measuring a patient’s glucose, have many ways to perform them: quantitative, qualitative, via an assay, via a culture, or via a test kit that changes colors. Tests that may be performed via a test kit (not requiring a lab tech’s clinical skill) can be done in the office and are placed on the CLIA-waived list. It is important to check the list and make sure that the exact test for glucose that you are performing is on the list, and that you are using the correct CPT code for that test. You don’t want to use the code for strep test done by culture without the -QW modifier (and get paid for that service) when you have performed the quick strep test done by kit (87880), which is on the CLIA-waived list.
GETTING OUT OF A LEASE
Q. Last year I signed a five-year lease with a laser company. I have been paying about $3,000 a month. I do not have many customers, and the payment is a big burden for me. I have tried to sell to other physicians without success. What can I do to get out of this lease? I am very desperate.
A. You need to read the contract in very close detail to see if there are exit or other similar clauses. It may cost you something, but that may be less expensive in the long run. You can also look at the other side of the equation. You must have expected to have customers when you leased the laser. What happened? Wrong audience? Too little marketing? If you can identify what went wrong and devise a way to change it, maybe you can begin to recoup your costs.
NO EMR REQUIREMENTS
Q. Is it mandatory for a small practice of one to two physicians to incorporate electronic medical records into their practice, or is it for practices with more than five physicians?
A.
There is no national regulation or law that requires anyone to have an EMR. There are many legislators saying it is a good idea, but there’s nada on the books.
DME STARK EXCEPTION
Q. This issue keeps coming back on my radar screen: As a primary-care practice, we don’t have much DME that we give our patients, but we do provide crutches, neck, wrist, elbow, and ankle bracing, heel cups, and the like, and then bill the patient’s insurance accordingly.
We have relatively few Medicare patients. When our Medicare patients fall, we usually recommend they go to the ER because of the likelihood of broken bones and other complications. So, giving DME to a Medicare patient is an infrequent occurrence around here.
Up to this point, I’ve been assured that these kinds of DME are excluded from the phase III rule of Stark, as they are needed to assure that the patient can safely leave our practice. Do you agree that there are some “small DME” items that primary-care practices can still provide to Medicare patients while staying within the law?
A.
Yes, there is an exception for ambulatory infusion pumps, blood glucose monitors, and a few other ambulatory devices necessary for the patient to be able to leave the office, such as crutches, canes, walkers, folding manual wheelchairs, etc. See page 79 of the Federal Register on the Bricker & Eckler Web site at: www.bricker.com/LegalServices/Practice/HCare/laws/cms090507.pdf
USING FOREIGN DRUGS
Q. Am I legally able to use a drug product manufactured abroad? Have there been any prosecutions and/or sanctions implemented to date? If I can purchase products at a discount and be assured of the source and the “equal” quality of the product so the only difference is the labeling, I would like to do so.
I do not care what people think; I care about treating patients as safely and efficiently as possible. For too long the medical profession has let the lawyers screw with us. If there is no state or law, then we (medical practices) should tell them to stop with the rhetoric.
Now, as to whether anybody will come after you, I don’t know. But I should think you’d want to take FDA claims that foreign drugs may not meet safety requirements seriously. Heaven knows the FDA has its problems, but there is no other way to know about the safety of a given product or how it has been stored or transported.
SAMPLE CONTRACT CANCELLATION LETTER
Q. Do you have an IPA termination letter sample? We want to write a letter to an HMO that we will no longer be contracting with them. For legal purposes, we do not know what is important to mention.
Q. One of our doctors has a standard progress note form. The physical examination part of that form is titled simply by body system. The doctor commonly hand-writes “normal” next to each system without describing specifically what part is normal. For example, he doesn’t write “lungs are clear, heart rate is normal without murmur, abdomen is soft and nontender,” and the like. Is this adequate documentation to use when meeting criteria for a level three or level four visit?
A. Please see page 23 of the Medicare documentation guidelines, online at: www.cms.hhs.gov/MLNProducts/downloads/eval_mgmt_serv_guide.pdf. It states that “normal” is sufficient for reporting on unaffected systems, though it’s not OK just to say an entire system is normal. Certainly, if he is testing blood pressure, etc., he’ll also want to document concrete findings.
TEST RESULT REVIEW CODING
Q. I would like to know what CPT and ICD code to use in case of a visit for test result review.
A. In most cases, payment for physician management decisions based on lab results are included in your fee under the medical decision-making component of an E&M service; it can’t be billed separately.
Now, if you are meeting the definition of an E&M visit, doing some HPI, review of systems, and medical decision making at that visit which is unique, you can bill the E&M. I suspect you are not doing all this, however. You are just telling the patient about the results.
SELECTING A BILLING COMPANY
Q. I am in the process of breaking away from a six-physician practice to open my own office. While together, we amassed quite a bit of hardware, software, and other electronic gadgets. I am realizing that the price of upgrades and maintenance for all this may be more of a luxury than a necessity. For one thing, as a large group we had in-house billing. As a soon-to-be solo doc, I am strongly considering outsourcing this service. What should I take into consideration when deciding among outside billing services? Should I look for one that would work off the same software I use? Should I abandon what I have and use whatever system they offer?
A. The key factor to consider with outsourced billing is vendor accountability. You need to understand how much they are collecting, whether and how they are working denials, what their cut is, and what you can do in the practice to improve collections. For example, if you lose money because of eligibility problems, that’s something your office needs to fix, not the billing company. It is worth paying more for better outcomes.
You also should look at software such as that from Navicure or athenahealth, which essentially do both billing and full revenue-cycle management. Think of these and other similar products as online management software aimed at billing and collections. It’s a step above outsourcing billing with lots of knowledge of payer contracts built in. This may or may not be a better option for you; investigate and decide.
Generally, I’d focus less on technology and more on how to retain as much of the money you’ve earned as possible.
