When billing to Medicare, there are a few issues of which you should be aware to ensure you are not sending claims that can create a ‘red flag’. With the new RAC audits that are coming, it is important to not send claims that can focus attention on your practice. Even if Medicare denies a claim, it is still in their system to help establish invalid or fraudulent billing patterns.
1. Follow Up Evaluation and Management (E&M) Codes – 9921X (1-5) –
There are two problem scenarios when billing E&M codes. They are:
A. Billing an Established Patient visit code in a global period. Medicare will always deny these claims unless the patient is seen for a completely different problem that is not related to the global period. To establish it is a different problem, the diagnosis must reflect the new chief complaint. Your documentation will need to reflect the new evaluation, diagnosis, and treatment plan of the new chief complaint. Do remember that a stab phlebectomy carries a 90 day global period and sclerotherapy carries a 10 day global period.
B. Billing an Established Patient visit code with a procedure. Medicare typically denies these codes as well because the re-evaluation of the patient must be ‘over and above’ the usual post-operative care associated with the procedure that was performed. For example, if the patient is coming in for a three month follow up appointment and you decide to perform sclerotherapy secondary to an ablation, you should not bill an additional E&M code as performing sclerotherapy is not unusual at the three month juncture.
2. Hematoma Billing (10140 and 10160) –
The treatment of a superficial hematoma is now considered part of the normal complications following a venous ablation and/or sclerotherapy procedure and will not be separately reimbursed by Medicare. A deep hematoma, typically with ultrasound guided needle placement, is still reimburseable as it is not a ‘normal’ complication.
3. Unbundling a Bundled Service (Billing for an ultrasound – 93971/76942 – during an ablation) –
The codes 36475 and 36478 are bundled codes which means the ultrasound services as well as the needle guided imagery and other additional services are included in the ablation code. Billing for the separate components is improper and will not be reimbursed. However, billing for a second insertion (36476 or 36479), stab phlebectomy, or sclerotherapy is allowed.
Some commercial payers follow Medicare guidelines while most others use them only as a basis. Our recommendation is to continue billing for those services like superficial hematomas to the commercial payers but not to Medicare. As we do not want the physician to double check the payer before treating a patient and coding, the onus should be on the billing department to ‘leave out’ inappropriate line items when billing Medicare.
I was wondering about billing for sclerotherapy during the global period for Medicare (and United Health Care) since they too now have the same global period policy. If I bill for a 36471 RT, do I need to wait the 10 days to bill for a 36471 LT, or is this considered a separate procedure? If I do NOT need to wait the 10 days, do I need to use a modifier or 58 or 79? Also, does the day of the procedure count as day 1 of the waiting period or is day 1 the day after the procedure? And is it 10 days flat or 10 days total? For example if a patient has sclerotherapy on a Monday, can they have their next treatment the following Thursday (assuming the day of the tx is day 1) or do they need to wait until the following Friday?