Elizabeth Woodcock Answers Your Questions about Medical Billing in 2016

As a follow up to our recent webinar, Getting Paid in 2016: What You Need to Know, speaker Elizabeth Woodcock and Kareo have answered some of the medical billing questions posed by participants. Tweet this Kareo story

Q: Can you bill the 99495/96 code with an office visit code on the same day?
A: The transitional care management codes (99495 and 99496) include an office visit, so it wouldn’t be appropriate to bill both on the same day. If, however, you see the patient for their TCM services on October 3, for example, after they were discharged from the hospital on October 1, and the patient returned for another visit on October 15, then you would bill the TCM code on October 3, and the appropriate E/M code on October 15.

Q: Since TCM claims will no longer need to be dated as the 30th day from the date of discharge, does the 30-day post-discharge period still apply? Example: Only one individual may report TCM services and only once per patient within 30 days of discharge.
A: The date of service is changed to the date of the E/M visit. There is no change to the number of physicians who can bill it—only one can do so. CMS reports that it will pay the “first eligible claim.” (See this link for the quote, as well as other information about TCM, noting that the change to the DOS is effective January 1, 2016, so it’s not updated in this document as of the publication of our Q&A summary.)

Q: We do visits with codes 99306-99310, can we use code 99497 in addition to these codes, and does it apply to POLST forms?
A: The American Medical Association (AMA) describes the code, 99497 as: “Including the explanation and discussion of advance directives, such as standard forms (with completion of such forms, when performed)…” Although POLST is not specifically mentioned, one could assume that it would fall under the definition of “standard forms” as it is the “standard” form, Physician Orders for Life-Sustaining Treatment. Importantly, however, the code can’t be billed exclusively for a form being completed. Please review to the entire definition to ensure that you are performing, documenting, and coding the service appropriately. Per the AMA, this code does not exclude 99306-10, and does not require a specific place of service. However, reimbursement determinations may differ by payer.

Q: On the Advance Care Planning, 99497 is the modifier added to the AWV or the 99497?
A: Modifier -33 is added to 99497 to ensure that the service is processed and paid by Medicare (versus requiring cost-sharing by the patient).

Q: Are there any Medicare increases/decreases for mental health? We are already struggling to get paid.
A: In the resources section of the webinar, there is a document that shows the changes for all specialties. You can log back into the recording to get this. Psychiatrists, Clinical Psychologists, and Clinical Social Workers will all experience a 0% change in reimbursement with Medicare in 2016, based on the changes to the Resource-based Relative Value Scale (RBRVS). Like all professionals, the overall update for 2016 for Medicare in 2016 is a negative 0.27%; you’ll also see the 2% sequestration cuts continuing to be applied to all Medicare payments in 2016.

If you are having problems with your billing performance/key performance indicators, the first step is to start looking at your metrics to figure out why. Are you receiving denials due to inaccurate patient information or improper coding? These are things you can fix with some work. Check out some of the resources available at www.kareo.com/resources for educational resources.

Q: Where can we find Physical Medicine/Physical Therapy CPT changes? Is there anything we should be aware of?
A: Check the resources section and download the overview on changes. PT and OT saw 0% change, Physiatrists will have a negative 1% based on the RBRVS changes applied by the CMS. Like all professionals, the overall update for 2016 for Medicare is a negative 0.27%; you’ll also see the 2% sequestration cuts continuing to be applied to all Medicare payments in 2016. For specific CPT® changes, check your specialty society for more details.

Q: I understand the payer cannot drop them due to the grace period via ACA, but as a practice, it's basically saying the patient does not have coverage and we don't see patients without insurance - are we REQUIRED to see the patient during the grace period?
A: The answer to this question would depend on the terms of your participation agreement with the payer, as well as whether or not you are bound by EMTALA or a state law. Because there are compliance issues associated with this question, I would suggest consulting your attorney, and analyzing the contract and associated appendices with the payer(s) on the exchange.

These question address only a few things covered in the webinar. For more details on what is coming in 2016, watch the webinar, Getting Paid in 2016: What You Need to Know, and download Elizabeth's resources from the resources section of the webinar player.


About the Author

Elizabeth Woodcock, MBA, FACMPE, CPC is a professional speaker, trainer and author specializing in medical practice management. She has focused on medical practice...

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