Coding Corner

The 2019 Medicare Physician Fee Schedule Rule, as proposed by the Centers for Medicare and Medicaid Services (CMS) in July 2018, garnered thousands of comments from the physician community.
The Centers for Medicare & Medicaid Services (CMS) has published numerous articles notifying Medicare providers and suppliers that they cannot bill beneficiaries enrolled in the Qualified Medicare Beneficiary (QMB) program for Medicare cost-sharing. QMBs have Medicare as their primary insurance and Medicaid as their secondary insurance. Medicare beneficiaries enrolled in the QMB program are not legally obligated to pay the deductibles, coinsurance, or copays for any Medicare-covered items or services. In addition, a state may or may not pay the deductible or coinsurance for the QMBs it insures, depending on its Medicaid program; most states do not.

The first question attempted to broadly elicit ways to reduce the burden associated with the documentation of patient E&M visits. The second question was designed to gain input from attendees on approaches that other payers take to both payment and documentation regarding E&M visits.

A National Organization of Rheumatology Managers (NORM) board member received this question from a member of the organization, “This is a query for anyone who is familiar with the billing and coding of infusions.

We frequently receive questions regarding the infamous “nurse visit,” and what documentation Medicare or other payers expect to see when billing the Current Procedural Terminology code 99211. So, what are the exact medical documentations that would support billing the evaluation and management (E&M) code 99211 alone or with other billable services?

You may know by now that the Centers for Medicare & Medicaid Services created Healthcare Common Procedure Coding System (HCPCS) code Q5102 to be used when reporting “Injection, infliximab, biosimilar, 10 mg.” The October 2017 HCPCS update included a new modifier, ZC Merck/Samsung Bioepis, to be used with HCPCS code Q5102.

In the office or clinic setting, a level 4 established patient office visit (CPT 99214) has always been the Evaluation and Management (E&M) code most physicians and nonphysician practitioners are cautious about billing to avoid payer scrutiny, yet they appreciate when they can bill it because the reimbursement is fair.
Your provider is out of town attending a medical convention, but one of his partners is in the office. Is the visit with the nurse practitioner eligible for incident-to billing?

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