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Coding Cues: Answers to your questions about...


Billing for family members; dual insurer errors; medication management

Key Points

Billing for family members

One of my associates is treating the father of the senior partner in our corporation and billing Medicare for his services. It's my understanding that CMS doesn't permit a physician to bill for medical services provided to his own family members or those of other doctors in his group, but others in our practice disagree. Who's right?

You are. According to the Medicare Benefit Policy Manual (updated in February 2007), it is inappropriate to bill Medicare for services rendered to immediate relatives of a provider or an owner of a provider. In this context, "owner" refers to the professional corporation employing the provider. "Immediate relative" is broadly defined as a husband or wife; natural or adoptive parent, child, or sibling; stepparent, stepchild, stepbrother, or stepsister; and grandparents, grandchildren, and their spouses. In-laws are also considered immediate relatives, even after divorce or death of the primary family member. In many cases, cohabitants are, too.

Dual insurer errors

While reviewing old accounts, we discovered numerous payment errors involving patients with primary and secondary coverage. Often, when the primary insurer issued a payment, our staff made an adjustment based on the allowed amount indicated on the EOB. Then the secondary insurer paid a portion of the write-off. The question now: Who should get the refund-the insurer or the patient?

That depends on the contractual arrangements between your practice and the insurers and on what was written off. If your practice had a contract with the primary insurer when the services were rendered, you are probably obligated to adjust the difference between the charge and the amount allowed by the insurer. If the allowed amount included a patient copay, however, the patient must pay, either out of pocket or via a payment from the secondary insurer.

If the difference between the charged and allowed amounts was written off, the second insurer overpaid and should get the refund. But if the write-off included the patient copay amount, reinstate that portion of it and post the payment.

Medication management

Patients with multiple health problems and multiple meds often ask-in many cases, repeatedly-why they take so many pills or why they need a particular drug. A time-consuming review of the function of each medication generally follows, along with a discussion of the benefit to the patient, indications and contraindications, and possible alternatives. Since this typically occurs after I've completed a physical exam, can I use code 90862 "Pharmacologic Management" in addition to the level of service for these patients?

The 90862 code would not be appropriate under the circumstances you describe. That's because the full description of this code is "Pharmacologic management, including prescription, use and review of medication with no more than minimal medical psychotherapy." You may, however, bill the visit based upon time if more than 50 percent of the visit was devoted to counseling and coordination of care. Be sure to document the total length of the visit and what percentage was spent in counseling, as well as the topics discussed.

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.

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