Coding Cues: Answers to your questions about...

Opting out; hydration therapy; rejected crossover claims

Key Points

Opting out

A member of my group is fed up with Medicare. He has his Medicare patients sign an Advance Beneficiary Notice prior to rendering services, then the patients pay him and he tells the billing department not to file claims for those services. I'm concerned that what he's doing isn't correct, and that his actions will negatively affect the group. Am I overreacting?

No. Having the patient sign an ABN for services that are routinely covered by Medicare is totally inappropriate and violates the provider participation agreement. If your colleague really wants to quit Medicare, he has the ability to "opt out." He'd have to file an affidavit with each Medicare carrier that has jurisdiction over his claims that states he forgoes payment from Medicare for two years, and that he will enter into private contracts with any Medicare patient who decides to continue to receive care from him and who will pay him his fee. But this can get tricky. If he opts out, you'll have to create a system for differentiating his patients from the rest of the group's. And you'd have to make sure the staff doesn't submit a claim for his Medicare patients by mistake.

Hydration therapy

We're confused about billing chemotherapy hydration. Many times a patient will present in a very dehydrated state and require hydration therapy before we can begin infusion therapy. Other times, the hydration is part of the protocol for the infusion therapy. Is the coding different for these two scenarios?

Yes. Code 90760 (intravenous infusion, hydration; initial, 31 minutes to 1 hour) should be used only when hydration is medically necessary but not required as part of the subsequent chemotherapy. Make sure you check how the insurer wants you to bill for this, such as listing the medically necessary hydration first or using a certain modifier.

Rejected crossover claims

Many of the claims we submit for Medicare patients who have Medigap insurance are being rejected. Since we aren't doing anything differently with these crossover claims, what's changed?

Effective Oct. 1, 2007, CMS completed a transition to a Coordination of Benefits Contractor (COBC) that issued Medigap insurers new five-digit identifiers. You're using the wrong one if your rejected claims contain the following advice: "Information was not sent to the Medigap insurer due to incorrect/invalid information you submitted concerning that insurer. Please verify your information and submit your secondary claim directly to that insurer."

You must include the new identifier on the original claim, whether you send it electronically or by mail, in order for the secondary claim to be processed correctly. CMS doesn't want you to contact the insurer to determine the number that the COBC assigned to it. You'll have to get that information from the Medigap billing ID spreadsheet by going to http://www.cms.hhs.gov/COBAgreement and clicking on Medigap Claim-based COBA IDs for Billing Purpose.

The author, vice president of operations for Reed Medical Systems in Monroe, MI, has more than 30 years' experience as a practice management consultant, as well as being a certified coding specialist, certified compliance officer, and a certified medical assistant.