Sean Callagy - Attorney and Entrepreneur: reimbursement

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Friday, April 29, 2016

Are MRI’s Reimbursable | Callagy Law

MRIs can be performed within five days of the insured event under certain circumstances

The purpose of this post is to help assist those with questions they have concerning their business or medical practice. The Callagy Law team is knowledgeable in many law practice areas and will frequently post topics ranging from Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. We hope to have this blog shed a light on many common questions.

Magnetic resonance imaging (MRI) is a test not normally performed within five days of the insured event. As a result, some insurance carriers will attempt to argue that these tests are not medically necessary and therefore, not reimbursable. However, clinically supported indication of neurological gross motor deficits, incontinence or acute nerve root compression with neurologic symptoms may justify MRI testing during the acute phase immediately post injury

In N.J. Coal. of Health Care v. Dept. of Banking & Ins., 323 N.J. Super. 207 (App. Div. 1999) at 247, the Court found that “[f]or cervical, thoracic and lumbar-sacral spine injuries, the first step in treating a patient involves, and logically so, a clinical evaluation by the appropriate health-care provider. Such an evaluation may include x-rays, CT scan, and an MRI, if necessary.”

Moreover, N.J.A.C. 11:3-4.5 (b) (5) states that these tests have been determined to have value in the evaluation of injuries, the diagnosis and development of a treatment plan for persons injured in a covered accident, when medically necessary and consistent with clinically supported findings, when used in accordance with the guidelines contained in the American College of Radiology, Appropriateness Criteria to evaluate injuries in numerous parts of the body, particularly the assessment of nerve root compression and/or motor loss.

The MRI test uses a magnetic field and pulses of radio wave energy to make pictures of organs and structures inside the body. The area of the body being studied is placed inside a special machine that contains a strong magnet. Pictures from an MRI scan are digital images that can be saved and stored on a computer for more study. The images also can be reviewed remotely, such as in a clinic or an operating room. In some cases, contrast material may be used during the MRI scan to show certain structures more clearly.

In many cases, MRI gives different information about structures in the body than can be seen with an X-ray, ultrasound, or computed tomography (CT) scan. MRI also may show problems that cannot be seen with other imaging methods.

According to the American College of Radiology, MRI testing should be reserved for cases of known or suspected soft tissue injuries such as disc herniations, ligament tears, epidural hematoma and spinal cord edema or hematoma, especially in the presence of a neurological deficit.

In Care Paths 1 and 5 for soft tissue injuries to the cervical spine and lumbar-sacral spine, respectively, though, an MRI may be administered if there are abnormal neurologic findings (i.e.: radiculopathy) and typically following a course of four weeks conservative treatment with no improvement in symptoms. In Care Paths 2 and 6 for soft tissue injuries to the cervical spine and lumbar-sacral spine with symptoms of radiculopathy, a minimum of two weeks conservative treatment without improvement in symptoms is recommended before administering an MRI.

As the MRI testing is appropriate during the clinical and diagnostic evaluation of injuries to the cervical and lumbar spine, especially if there are abnormal neurologic findings; these tests are in fact reimbursable if performed within five days of the insured event.

We hope you found the information provided in this article helpful to various questions you may have had concerning the healthcare industry. For information pertaining to our services for medical providers, please click here. Please note, Callagy Law has recovered over $200,000,000 for medical providers, and that number grows daily. Please free to reach out to Sean Callagy of Callagy Law at any time for questions you may have concerning personal and business matters. Callagy Law offices are located conveniently in Paramus, NJ. Beyond the scope of information, Sean Callagy has developed multiple areas of our healthcare legal practice and business coaching. Feel free to connect with us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

Learn More About Callagy Law Here:

Are MRI’s Reimbursable | Callagy Law #CallagyLaw, #Dobi, #HealthcareRecovery, #MagneticResonanceImaging, #Mri, #NjCoalOfHealthCare, #Recovery, #Reimbursable, #Reimbursement, #XRay, #Xray

Tuesday, February 9, 2016

Proper Use of Modifier 59 For Reimbursement | Callagy Law

PIP PRACTICE TIP: PROPER USE OF MODIFIER -59 FOR REIMBURSEMENT OF SERVICES THAT ARE “SEPARATE AND DISTINCT” FROM OTHER SERVICES BILLED ON SAME DATE

The following article was written by Callagy Law’s Legal Team, and will focus on many common questions and concerns surrounding new developments, legal matters, and other procedures within the field of healthcare law Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. Our mission is to answer any questions and give knowledge to many different aspects of these matters.

It is important for medical providers to correctly use modifier 59 in order to receive reimbursement for codes that are indeed “separate and distinct” from other services billed on the same date of service. Modifier 59 is defined by the CPT Manual as follows:

“Distinct Procedural Service: Under certain circumstances, it may be necessary to indicate that a procedure or service was distinct or independent from other non-E/M services performed on the same day. Modifier 59 is used to identify procedures/services, other than E/M services, that are not normally reported together, but are appropriate under the circumstances. Documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual. However, when another already established modifier is appropriate, it should be used rather than modifier 59. Only if no more descriptive modifier is available, and the use of modifier 59 best explains the circumstances, should modifier 59 be used. Note: Modifier 59 should not be appended to an E/M service. To report a separate and distinct E/M service with a non-E/M service performed on the same date, see modifier 25.”

To summarize, modifier 59 is used to indicate a separate and distinct procedural service for surgical procedures, non-surgical therapeutic procedures or diagnostic procedures that were independent of other services performed on the same day, including, but not limited to the following:

Different session

Different site or organ

Separate excision/incision

Separate lesion

Separate injury.

The Medicare National Correct Coding Initiative (“NCCI”) promulgated edits, which contain pairs of CPT codes that generally should not be billed together by a provider for the same patient on the same date of service. Under certain circumstances, a provider may bill for two services in a NCCI code pair and include a modifier that would bypass the edit and allow both services to be paid.

Modifier 59 is one of over thirty modifiers that can be used to bypass an NCCI edit conflict. A modifier, however, cannot be appended to a CPT Code for the sole purpose of bypassing an NCCI edit if the clinical records do not justify its use. Modifier 59 is used to represent that a provider performed a separate and distinct procedure or service for a patient on the same day as another procedure or service. Modifier 59 should be attached to the secondary, additional, or lesser service in an NCCI code pair. Pursuant to the “Medicare Claims Processing Manual,” in order to properly bill with modifier 59, the provider’s documentation must show that the service was distinct from other services performed that day.

A common misuse of modifier 59 is when a medical provider uses it on the sole basis that the narrative description of the two codes is different. The two “different procedures” must be performed at separate anatomic sites or at a separate patient encounter on the same date of service in order to justify the use of modifier 59.

Notably, the treatment of contiguous structures in the same organ or anatomic region does not constitute treatment of different anatomic sites and should not be billed with a 59 modifier. For instance, arthroscopic treatment of structures in adjoining areas of the same shoulder constitutes treatment of a single anatomic site.

Modifier 59 should only be used in circumstances where no other modifier more appropriately describes the relationship of the two procedure codes. For example, if two procedures are performed on different sides of the body, modifiers RT (“right”) and LT (“left”) or another pair of anatomic modifiers should be used, not modifier 59.

In sum, modifier 59 is used appropriately in the following circumstances:

for different anatomic sites during the same encounter only when procedures which are not ordinarily performed or encountered on the same day are performed on different organs, or different anatomic regions, or in limited situations on different, non-contiguous lesions in different anatomic regions of the same organ;

when the procedures are performed in different encounters on the same day;

when two timed procedures are performed in different blocks of time on the same day;

for a diagnostic procedure which precedes a therapeutic procedure only when the diagnostic procedure is the basis for performing the therapeutic procedure;

for a diagnostic procedure which occurs subsequent to a completed therapeutic procedure only when the diagnostic procedure is not a common, expected or necessary follow-up to the therapeutic procedure.

We hope you have found this information helpful and interesting. Please reach out to us here with any questions or comments regarding healthcare legal matters, or if you are a medical provider that has questions regarding Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. Feel free to search us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

Learn More About Callagy Law Here:

Proper Use of Modifier 59 For Reimbursement | Callagy Law #CallagyLaw, #CptManuel, #HealthcareRecovery, #LawFirm, #MedicareNationalCorrectCodingInitiative, #Modifier59, #Ncci, #Reimbursement

Tuesday, January 19, 2016

Reimbursement For Fewer Than All CPT Codes Billed | Callagy Law

IS THIS PERMISSIBLE UNDER NEW JERSEY PIP REGULATIONS?

After searching various sources, we have found many people have questions when it comes to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. Do you have questions pertaining to reimbursement? Do you know what to do if problems arise? With articles written by Callagy Law’s law team, this blog will focus on many common questions and concerns surrounding legal matters which can arise in the field of healthcare law.

Let’s say someone injured their right knee in a motor vehicle accident and underwent physical therapy but still had residual pain and deficit of function. The patient went to an orthopedist, who recommended and performed a right knee arthroscopic surgery. The doctor billed two CPT arthroscopic knee surgery codes, Codes 29875 (limited synovectomy) and CPT Code 29877 (debridement/shaving of articular cartilage, or chondroplasty). The Operative Report even shows both these procedures were performed as part of the knee surgery. Why, then, did the PIP insurer only reimburse the doctor for treatment under CPT Code 29875? Isn’t the doctor entitled to separate reimbursement for the procedures performed under CPT Code 29877? The short answer is no, as discussed below.

Reimbursement under New Jersey PIP law is generally governed by N.J.A.C. 11:3-29.4, “Application of medical fee schedules.” This regulation states providers and payors shall use the National Correct Coding Initiative (NCCI) Edits as updated by CMS (The Centers for Medicare & Medicaid Services.) Under the NCCI Edits, one CPT Code may be considered bundled into another Code, and payment will only be due for the one Code. Other times, a modifier may be required in the billing of the second Code and documentation to show the second procedure was “over and above” the treatment provided under the first Code. Other times, Codes are listed but there is no conflict and no barrier (from this perspective) to separate reimbursement for both Codes.

More specifically, the governing PIP regulation, N.J.A.C. 11:3-29.4 (g)(1) states:

Artificially separating or partitioning what is inherently one total procedure into subparts that are integral to the whole for the purpose of increasing medical fees is prohibited. Such practice is commonly referred to as “unbundling” or “fragmented” billing. Providers and payors shall use the National Correct Coding Initiative (NCCI) Edits, incorporated herein by reference, as updated quarterly by CMS and available at http://www.cms.hhs.gov/NationalCorrectCodInitEd/. Modifier 59 and other NCCI-associated modifiers should not be used to bypass an NCCI edit unless the proper criteria for use of the modifier are met. Documentation in the medical record must satisfy the criteria required by any NCCI-associated modifier used. For more information on the criteria for the use of modifiers, see the NCCI Policy Manual and Modifier 59 Article referenced in (g) above.

Therefore, to determine if a medical provider is entitled to separate reimbursement for multiple CPT Codes, the NCCI Edits must be reviewed. Information on NCCI Edits may be found at https://www.cms.gov/Medicare/Coding/NationalCorrectCodInitEd/index.html.

A pair of codes must be looked up to determine if there is an NCCI edit. If the codes do appear on the list of NCCI edits, check if the edit was in effect the date the treatment was performed. There is a column for “effective date,” as well as “deletion date.”

Let’s assume your pair of codes are on the NCCI edit list and the edit was in effect when the treatment was provided. The next issue is whether the edit is designated a “0”, a “1” or a “9.” If your pair has a “9” designation, there is no conflict. If your pair has a “0” designation, you are not entitled to separate reimbursement for both codes. If, however, your pair has a “1” designation, you may be entitled to separate reimbursement if the conditions for separate reimbursement are met. The conditions are billing with a proper modifier (often a -59 modifier) and having the proper documentation to support separate reimbursement. The type of documentation generally required for separate reimbursement is proof the second treatment was “over and above” or “separate and distinct” from the treatment provided under the first code.

In our example above, CPT Code 29877 is not separately reimbursable from CPT Code 29875. The NCCI edit conflict is set forth below, and contains a designation of “0,” meaning no modifier and documentation will overcome the bundled designation of the second code.

Column 1

Column 2

* = In existence prior to 1996

Effective Date

Deletion Date

*=no data

Modifier

0=not allowed

1=allowed

9=not applicable

29875

29877

20030401

An example of a “1” designation is billing for an arthroscopic shoulder surgery under CPT Code 29827 (rotator cuff repair) and 29825 (lysis and resection of adhesions). The pair of these codes has a “1” designation. Use of a -59 modifier with adequate documentation justifying the second code may result in separate reimbursement.

29827

29825

20030701

It is important to be familiar with current NCCI Edit conflicts and requirements to obtain separate reimbursement, when applicable.

We hope you found the information provided in this article helpful to various questions you may have had concerning the healthcare industry. For information pertaining to our services for medical providers, please click here. Please note, Callagy Law has recovered over $175,000,000 for medical providers, and that number grows daily. Please free to reach out to Sean Callagy of Callagy Law at any time for questions you may have concerning personal and business matters. Callagy Law offices are located conveniently in Paramus, NJ. Beyond the scope of information, Sean Callagy has developed multiple areas of our healthcare legal practice and business coaching. Feel free to connect with us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

Learn More About Callagy Law Here:

Reimbursement For Fewer Than All CPT Codes Billed | Callagy Law #CptCodes, #NewJerseyLaw, #NewJerseyRegulations, #Reimbursement

Tuesday, December 22, 2015

Reimbursement Under New Jersey PIP laws | Callagy Law

When does UCR (the usual, customary and reasonable amount) apply?

The purpose of this post is to help assist healthcare providers and the public with questions they have concerning topics related to Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. The Callagy Law team is knowledgeable in all aspects of these sorts of legal matters and will frequently post topics in this field. We hope to have this article shine a light on many common questions.

Medical providers may wonder why a PIP insurance company pays less than the amount billed. For example, perhaps a north region doctor bills $200.00 for an office visit billed under CPT Code 99214. The PIP insurer reimbursed the doctor $125.71. Is a balance due? The general answer is no, and that is because a medical fee schedule governs the reimbursement for this treatment. Other times, however, there may not be a medical fee schedule at all. What is the standard of reimbursement in that instance?

To determine the proper amount due, a review of the New Jersey PIP reimbursement structure is in order. This discussion concerns reimbursement amounts, not whether PIP benefits apply in the first place. Other issues, such as medical necessity and causality, factor into such right to reimbursement.

As to the amounts due, it must be recognized the Department of Insurance and Banking (“DOBI”) has promulgated many medical fee schedules. These payment schedules cover a variety of types of medical providers, as well as a wide array of CPT Codes. A summary of these fee schedules may be found at http://www.state.nj.us/dobi/pipinfo/aicrapg.htm.

Therefore, the first step is to review the fee schedules listed on the DOBI website and see if the type of medical provider and CPT Code for the treatment is listed. Also, there are times a medical fee schedule may not apply. For example, if a trauma doctor provides trauma services and bills with a –TS modifier, the fee schedule amount will not apply, but rather, a UCR standard applies. N.J.A.C. 11:3-29.2 defines trauma services as follows:

“Trauma services” means the care provided in the Level I or Level II trauma hospital to patients whose arrival requires trauma center activation. It does not include transportation to the hospital, treatment of patients whose arrival at the hospital does not require trauma activation or outpatient visits after a patient who has received trauma care is discharged from acute care.”

What is UCR? UCR is the usual, customary and reasonable amount due for treatment. How is UCR determined? The governing DOBI regulation, N.J.A.C. 11:3-29.4, provides the amount due will be that of a similar code on a medical fee schedule. If there is no similar code, UCR is determined by a process. First, the medical provider submits its customary bill. It is imperative the provider retain exemplar Explanation of Benefits showing the payment received from other payors. The PIP insurer may then determine the reasonableness of the fee by comparing its experiences with that provider and other providers in the region. The PIP carrier may also rely upon national databases of fees to determine the reasonableness of the bill for the provider’s geographic region.

Callagy Law handles many PIP arbitrations in which UCR is a significant issue. Our success generally depends upon the UCR proofs we are able to introduce at hearing. We implore our medical providers to retain copies of exemplar EOBs to show what PIP carriers are reimbursing them for treatment that is not subject to a medical fee schedule. It will help in our ability to obtain proper reimbursement at UCR if we have the supporting documents.

We hope you have found this information helpful and interesting. Please reach out to us here with any questions or comments regarding healthcare legal matters, or if you are a medical provider that has questions regarding Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance.. Feel free to search us on Facebook, Twitter or LinkedIn! Additionally you can subscribe to our daily videos on YouTube.

Learn More About Callagy Law Here:

Reimbursement Under New Jersey PIP laws | Callagy Law #CallagyLaw, #Cpt, #DepartmentOfInsuranceAndBanking, #Dobi, #MedicalProviders, #NjPipLaws, #PipLaws, #Reimbursement, #Ucr

Tuesday, December 8, 2015

Hospital Anesthesia Services Potentially Recoverable! | Callagy Law

Are Hospitals Entitled to Reimbursement for anesthesia services?

The following article was written by Callagy Law’s Legal Team, and will focus on many common questions and concerns surrounding new developments, legal matters, and other procedures within the field of healthcare law Medical Revenue Recovery, PIP, Workers Compensation, and Commercial Insurance. Our mission is to answer any questions and give knowledge to many different aspects of these matters.

Anesthesia is a way to control pain during a surgery or procedure by using medicine called anesthetics. General anesthesia is used to ensure comfort and safety during certain types of procedures. Anesthesia effects and helps control a patient’s breathing, blood pressure, blood flow, and heart rate/rhythm, among other things.

When you get general anesthesia, in layman’s terms, “put under,” you are completely unconscious and immobilized. General anesthesia may be administered via gas, an IV line or a combination of both. Typically, major/complex procedures that require a long period of time to perform require general anesthesia.

A patient may present to an Ambulatory Surgery Center (ASC) or a Hospital facility to undergo these types of major/complex procedures. In a case where a patient presents to a Hospital facility to undergo a procedure, the Hospital provides the anesthesia and necessary supplies. The hospital provides the equipment, supplies and sometimes staff required to safely and effectively deliver anesthesia services during the procedure. The specific resources that the hospital provides vary depending upon the type of anesthesia the patient requires and the patient’s particular medical condition. The staff will also vary according to the hospital. Sometimes the staff are outside anesthesiologists working in the hospital, and sometimes, they are hospital employees.

So how is this billed to the insurance carrier? In the case of the outside anesthesiologist, they will bill separately for his or her professional services, as will your surgeon and the other physicians who provide services for you while you are hospitalized. They will bill for part of the services, called the professional component. The hospital will issue a separate bill for all of the services and items the hospital provided during your hospitalization and that bill will include charges for the hospital’s role in the delivery of anesthesia services based on the specific type anesthesia services a patient receives. The hospital’s bill is for what’s called the technical or facility component.

An insurance carrier may attempt to argue that the Hospital improperly submitted what constitutes duplicate billing of anesthesia for the date(s) of service that are at issue. Usually, this is based upon the fact that the anesthesiologist, who administered the anesthesia services on the date(s) in question, had already submitted his/her independent bills for the “same” instance of anesthesia services for the procedure. This is incorrect, as both the anesthesiologist and hospital are each billing only for their portion of the services provided.

The insurance carrier may also attempt to argue that pursuant to N.J.A.C. 11:3-29.4(o)(7) anesthesia materials, including the anesthetic itself, and any materials, whether disposal or reusable, necessary for its administration are not entitled to a separate charge. As such, the Hospital facility would not be entitled to reimbursement for anesthesia because anesthesia services were “bundled” into the main surgical code. However, this is not always the case.

There are several arguments that Callagy Law has successfully advanced where arbitrators in NJ No-Fault (PIP) arbitrations have determined that such anesthesia services are separately reimbursable to the hospital. Namely, if the procedure was an inpatient procedure, if it was an emergency procedure, or if it was an outpatient surgical procedure, where the main surgical code billed was not on the Hospital Outpatient Surgical Facility (HOSF) fee schedule. In each of these examples, there are strong arguments to be made that the technical/facility portion of anesthesia should have been reimbursed to the Hospital, despite the carrier’s arguments to the contrary.

Therefore, Hospital facilities are sometimes entitled to separate reimbursement for anesthesia services in addition to the anesthesiologist’s separate and distinct bill for his/her own personal services.