Posts Categorized: Medical Billing Tips

Coding Questions and Answers

No Comments

Q.  If we cannot find a CPT code that exactly describes the procedure done, can we bill a code that closely describes the procedure?

A.  If a service is performed for which you cannot find a CPT code, it is always best to use an unlisted procedure code rather than the closest possible code. Within the CPT book are a number of specific codes that have been designated for reporting unlisted procedures. They are listed at the end of each section. By billing a code that was not performed completely, it may be interpreted as fraud because it involves billing for services that were not performed.

Q. What is the site of service differential and how does it affect reimbursement?

A. There is a listing of procedures that are most often performed in a physician’s office. If these services are provided in another location, such as in a hospital outpatient setting, payment for these services is reduced.

Q. Is there a difference between a copayment and coinsurance?

A. People often use these two terms interchangeably. However, there is a difference. A “copayment” (or copay) is the out-of-pocket expense to the patient at the time of service, usually $10, $10, or $25, and is common with an HMO-type insurance plan. “Coinsurance” refers to the patient’s out-of-pocket expense after the insurance has paid its liability in a traditional health insurance plan. For example, if a patient has such a plan that pays 80 percent after their calendar year deductible, the patient’s coinsurance would be 20 percent. This is the amount the patient is responsible for and can be collected by the physician’s office either at the time services are rendered or after the insurance has paid its percentage of covered charges.

Q. Can I just look up ICD-9 codes in Volume 2, the Alphabetic Index? What is the purpose of Volume 1, the Tabular section?

A. You should never code directly from the Index. Fifth digits are often omitted from the Index entries. You should always confirm a code from the Index by looking it up in the Tabular section. The Tabular section contains additional instructions, Includes and Excludes notes, flags that indicate when a 4th and 5th digit is required, and other valuable information that will aid you in proper code selection. Depending on just the Index for code selection is to invite error.

Q. We had a claim denied due to “concurrent care.” What does this mean and how do we handle this?

A. Concurrent care is when a patient is being treated by two different providers for different problems at the same time. For example, a patient may be hospitalized by a general surgeon for an operation and may also be seen while hospitalized by a cardiologist for an unrelated cardiac condition. Frequently claims will be denied as a duplication of services when the patient was seen by two physicians on the same day when no duplication actually occurred. Each claim must have a different ICD-9 code for the services provided by each physician, which support and justify the need for the services provided.

Q.  I am having trouble getting a commercial insurance carrier to pay on a claim. Any suggestions?

A. You might want to try getting the patient involved. The insurance contract is between the insurance carrier and the patient. The provider is an outside party. If you are not getting a response from an insurance carrier on an unpaid claim, let the patient know you are having a problem and ask them to contact the insurance carrier. In many cases, this will result in a quick resolution of the problem.

For more information about Medical Billing and Coding visit our online course for Understanding Coding and Modifiers
For more online courses visit our complete Online Medical Billing Study Course

Modifier -59 clarification

No Comments

Modifier-59 is often used incorrectly in coding procedures. Therefore,  CMS has established four new HCPCS modifiers that are to define specific subsets of the -59 modifier.


They are:

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.


These additional modifiers go into effect on January 5, 2015.


There are many in the medical billing industry that are still confused as to when to use these modifiers. These new modifiers are not consistent with some of the coding regulations  (example: dermatologists are BIG users of modifier 59 because they frequently perform procedures on different unrelated lesions and sites.  There about 49,000+ CCI bundles that affect dermatology). Since we have a few more months for implementation, we are looking for an easier explanation with examples to share with you and will be updating this as we learn more. Stay tuned!!


For further information about coding see our course at:

Most Common Error on the New CMS 1500 (rev 02-12)

No Comments

The new version, CMS 1500 (rev 02-12) form has been being used now for just over two months after it’s April 1st implementation.  The most common error that providers are making when completing the new CMS form is on box 17, the referring/ordering/supervising physician field.  On the new CMS 1500 (rev 02-12) a qualifier is required to indicate whether the provider is referring, ordering, or supervising.  Below is a recap:


On the newly revised CMS 1500 (rev 02-12) form which will become mandatory by Medicare on April 1, 2014, providers will have to use the appropriate qualifier to indicate referring, ordering and supervising physicians. On the old CMS 1500 (08-05) form it wasn’t necessary to differentiate between referring, ordering and supervising physicians. The provider’s name and NPI were simply entered in box 17. With the new form Medicare is requiring that the appropriate qualifier is used to differentiate between referring, ordering, and supervising physicians by using the following qualifiers:


◦DN -> to indicate a Referring Provider
◦DK -> to indicate an Ordering Provider
◦DQ -> to indicate a Supervising Provider


These qualifiers should be entered to the left of the dotted vertical line in box 17. If the qualifier is not present the services will be denied.


Is Your Doctor Breaking the Law? The truth about waiving co-pays revealed

No Comments

Most people in the medical billing industry are aware that there are compliance issues with professional courtesies or the waiving of patient responsibilities but there still seems to be a lot of confusion surrounding the issue. What they are not aware of is that the practice of waiving the patient responsibility may actually be breaking the law.


Many providers do not understand why they cannot decide to extend a break for services rendered to a family member or friend. They feel that they have a right to choose if they want to collect the money that the insurance carrier deems to be the patient’s share.


The insurance carriers feel differently about the situation. They feel that by waiving the patient responsibility the provider is intentionally charging a different price for the same service. For example, a provider charges $100 for a level 3 established patient office visit and the patient’s insurance carrier pays $80 and the patient has a $20 copay. If the provider waives the $20 copay the insurance carrier feels that the provider is willing to accept $80 for the level 3 established patient office visit. Based on that they feel that they overpaid the provider $20. They should have paid $60 and the patient should have paid $20.


Why does the insurance carrier feel this way? Basically all of these concepts, deductible, co-pay and co-insurance, are cost share obligations.  The rules of managed care state that the patient CANNOT see the doctor until they make their co-payment. Managed care is governed by federal law and is not open to interpretation. To “write-off” a co-pay, or to allow a patient in to see the doctor without collecting the co-payment, is against federal law.


Federal law never allows waivers of patient responsibility to be offered as part of any advertisement or solicitation. Basically a provider cannot use the enticement of waving the patient’s responsibility to get a patient in the door. A provider may think that they can advertise a special where they will waive the patient’s co-pay for a new patient consultation to try to get more patient’s into their practice but this is illegal.


Most managed care contracts that providers sign when enrolling to be participating with an insurance carrier forbid waiving patient responsibility. They consider such waivers to constitute insurance fraud, misrepresentation and unfair competition. If an insurance carrier discovers a provider is waiving co-payments the insurance carrier has the right to stop payments on a claim and/or recover amounts already paid on claims.


Professional courtesies must be distinguished from waiving patient responsibilities. A professional courtesy is when the provider waives the entire fee for a physician, or the dependent of a physician. A professional courtesy may also be a discount such as 50% for such an individual or the provider may choose to waive only the patient’s out of pocket expenses as well. This is known as accepting “insurance only” as payment in full. The issue is that this professional courtesy is often extended to many others such as staff, family of staff, friends, etc.


Generally if the professional courtesy is the waiving of the entire fee or a percentage of the entire fee it is considered legal. However, if the professional courtesy is waiving the co-pay or the patient responsibility it is generally considered illegal especially if the patient has a federal insurance plan such as Medicare. This is true even if the patient is a physician.


It would also be considered illegal if the professional courtesy was extended to a patient who is in a position to refer business to the provider. This could be considered fraud and abuse, especially in the case of Medicare patients. Waiving patient responsibility for Medicare patients violates a federal statute that states that the provider knows that waiving the patient responsibility is likely to influence the patient to seek care from that provider.


Some individual states agree with the insurance carrier’s perception and have declared the insurance only courtesy is insurance fraud. If the provider accepts insurance only then the state feels that they are misrepresenting their fees by charging insurance carriers a fee that is higher than the fee that they actually intend to collect.


There are many situations where waiving the patient’s responsibility either in the form of a deductible, co-pay or coinsurance is deemed illegal. Federal plans and managed care plans are covered under federal law and most commercial plans, depending on the state, are covered under state laws. If not illegal, it is most likely a violation of the provider’s contract with the insurance carrier. Violating the contract may result in the provider being removed from the insurance carrier panel.


Basically, providers are not supposed to ‘forgive’ patient responsibilities without proof of financial hardship. Such financial hardship cases must be consistent and not provided routinely and the hardship should be documented in the patient’s chart. Therefore, the best course is to avoid waiving the patient responsibility unless a financial hardship has been established. Office policies should be reviewed regarding any courtesy discounts to make sure that they are compliant.


To learn more about this and other legal issues check out our online course: HIPAA, HITECH and Regulatory Issues