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State laws and regulations that affect your medical practice

1. What are the top 10 billing errors encountered by TrailBlazer Health Enterprises, the contracted Medicare carrier for Texas?

( 1 ) Duplicates: when a claim duplicates an existing claim. If you are questioning the reason for nonpayment of a claim, call Provider Inquiries at (866) 211-5808. DO NOT refile the claim until you know it is necessary.

( 2 ) Beneficiary Eligibility: Patient does not have Medicare eligibility for the service provided. Verify the Medicare number as well as the patient's effective date for Medicare Part B on the patient's Medicare card. File the claim with the number exactly as it is printed on the card. To obtain Medicare eligibility, call TrailBlazer at (877) 392-9865.

( 4 ) Invalid Code: Service was billed with an invalid procedure code or modifier.

( 5 ) CLIA: You must submit a Clinical Laboratory Improvement Act of 1988 (CLIA) number on each claim for lab services. Report the CLIA number of the laboratory that performed the testing in Item 23 of the CMS-1500 form, along with the name and address of the performing lab in Item 32. If the claim is not for a referral service, enter the CLIA number in Item 23, or if billing electronically, in 2-180-REF02 (X4) loop 2300.

( 6 ) Bundled Services: Payment for B status code services is always bundled into payment for other services. These codes have no relative value units or established payment amount, and no separate payment is ever made. Go to the Medicare page on the TMA Web site, and click on "National Physician Fee Schedule Relative Value File" under Related Files to find out if the procedure codes you are billing are B status codes.

( 7 ) Medical Necessity: Service is deemed not medically necessary. Check the Medicare newsletters and the Local Coverage Determination for lists of covered diagnoses for a particular service. Links to both are on the Trailblazer Part B Texas main page.

( 8 )Non-covered Services: Patient does not have Medicare eligibility for the service provided. Be aware of services that Medicare excludes, such as personal comfort items; pills and other medications not administered by injection; routine immunizations, physicals, and dental care; and lab tests and X-rays performed for screening purposes (except screening mammograms).

( 9 ) Medicare Secondary Payer: Medicare is the secondary payer for the claim. This is due to the fact that the care of a Medicare patient may be covered by another payer such as workers' compensation, an employer health plan, auto insurance, the U.S. Department of Veterans Affairs, or Medicare Part A. Obtain routine information concerning working/retirement status of each Medicare patient with each visit.

( 10 ) Provider eligibility: The billing physician is not a current Medicare participant. Verify if the correct date of service appears on the remittance notice (RN), and follow procedures for having an error corrected, if necessary. If the RN has the correct date, there may be an issue with the effective date and/or termination date of your Medicare billing number; contact TrailBlazer's Provider Enrollment Helpline at (866) 528-1602 for information.

TMA Practice Web site, E-Tips

2. What information must be included by Texas physicians on Medicaid claims?

Eligible providers are required to provide separate claim information for each eligible recipient. Claims must be complete, accurate, and as specified by the health insuring agent with departmental approval. Required information includes, but is not limited to, the following:

( 1 ) name, address, and appropriate identification number of the provider of services or supplies or both;

( 2 ) the date of the claim;

( 3 ) the name, address, identification number, and date of birth of the individual who received services or supplies or both;

( 4 ) the type of such services or supplies or both provided;

( 5 ) the date(s) each service or supplies or both were provided;

( 6 ) the amounts of each charge for the various types of services or supplies or both;

( 7 ) the total charge for services or supplies or both;

( 8 ) credits for any payments made at the time of submission of the claim, including payments made by private health insurance and under Medicare;

( 9 ) indication that the eligible recipient has health, accident, or other insurance policies, or is covered by private or governmental benefit systems, or other third party liability, when reported, known, or suspected;

( 10 ) the date of the eligible recipient's death, if applicable;

( 11 ) a certification by the eligible provider or his or her designated representative which meets the requirements of 45 Code of Federal Regulations, § 250.80.

1 TX ADC § 354.1001

3. In what format should medical bills be submitted for payment to the Division of Workers' Compensation?

( a ) Health care providers shall submit medical bills for payment:

( 1 ) on standard forms used by the Centers for Medicare and Medicaid Services (CMS);

( 2 ) on applicable forms prescribed for pharmacists and dentists;

( 3 ) in electronic format.

( b ) Pharmacists and pharmacy processing agents shall submit bills using the current National Council for Prescription Drug Programs (NCPDP) Universal Claim Form (UCF) for health care provided on or after January 1, 2007.

( c ) Dentists shall submit bills using the current American Dental Association claim form.

( d ) All information submitted on required billing forms must be legible and completed in accordance with Division instructions.

28 TX ADC § 133.10

4. May a physician bill for services before he or she is credentialed with a health plan?

No. Each physician must be individually credentialed before he/she may treat patients enrolled in that health plan.

Texas Medical Association Web site; TMA FAQs

5. Under what circumstances may a physician's services be billed under the name of another physician?

The only time it is appropriate to bill under another physician's name is if there is a locum tenens (substitute/representative) arrangement. Employee physicians must still bill under their own names. It is not appropriate to bill using established physician provider numbers while the new physician is being credentialed.

Texas Medical Association Web site; TMA FAQs

6. May a physician bill for both a preventive medicine visit (99381-99397) visit and an office visit (99201-99215) on the same day?

CPT instruction clearly states that it is appropriate to bill for both services on the same day. The – 25 modifier should be placed upon the office/outpatient code to indicate that a significant, separately identifiable service was provided. However, not all carriers will pay for both.

Texas Medical Association Web site; TMA FAQs

7. What are the guidelines for hiring an outside billing service in Texas?

When considering contracting with an outside billing service, minimize your risk by doing the following:

Texas Medical Association Web site; TMA FAQs

8. Must a physician state in writing the procedure and costs for non-covered services?

There is no state statute or rule that requires a physician to provide in writing a description of the procedure and costs incurred for non-covered services. However, if the patient in question is a Medicare patient, physicians are not supposed to use blanket waivers for non-covered services. Medicare expects a physician to only ask a patient to sign a Waiver of Liability (a/k/a Advance Beneficiary Notice) when there is an expectation that the specific services in question are non-covered. It is not to be used on a routine basis. A physician can bill for services he knows are non-covered if the patient's secondary insurance requires a denial by the primary insurer. There is a modifier (-GA) that can be used in such cases.

Texas Medical Association Web site; TMA FAQs

9. Is an out-of network provider allowed to offer a patient a discounted rate?

If the physician is out of network, he/she can offer discounts at any rate. However, it is important that this office-wide policy be extended to all patients.

Texas Medical Association Web site; TMA FAQs

10. May a physician withhold access to a patient's medical record because of a past due account?

No. It is unethical for a physician to refuse access to a patient's medical records because of an unpaid balance for medical services.

Texas Medical Association Web site; TMA FAQs

Copyright Kern Augustine Conroy and Schoppmann, P.C. Used with permission.

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