Medicare coverage - Physician Expense for Surgery, Childbirth, and Treatment for Infertility

Surgery and Childbirth


Skilled medical management is covered throughout the events of pregnancy, beginning with diagnosis, continuing through delivery and ending after the necessary postnatal care. Similarly, in the event of termination of pregnancy, regardless of whether terminated spontaneously or for therapeutic reasons (i.e., where the life of the mother would be endangered if the fetus were brought to term), the need for skilled medical management and/or medical services is equally important as in those cases carried to full term. After the infant is delivered and is a separate individual, items and services furnished to the infant are not covered on the basis of the mother’s eligibility.

Most surgeons and obstetricians bill patients an all-inclusive package charge intended to cover all services associated with the surgical procedure or delivery of the child. All expenses for surgical and obstetrical care, including preoperative/prenatal examinations and tests and post-operative/postnatal services, are considered incurred on the date of surgery or delivery, as appropriate. This policy applies whether the physician bills on a package charge basis, or itemizes the bill separately for these items.

Occasionally, a physician’s bill may include charges for additional services not directly related to the surgical procedure or the delivery. Such charges are considered incurred on the date the additional services are furnished.

The above policy applies only where the charges are imposed by one physician or by a clinic on behalf of a group of physicians. Where more than one physician imposes charges for surgical or obstetrical services, all preoperative/prenatal and post-operative/postnatal services performed by the physician who performed the surgery or delivery are considered incurred on the date of the surgery or delivery. Expenses for services rendered by other physicians are considered incurred on the date they were performed.



Treatment for Infertility
Reasonable and necessary services associated with treatment for infertility are covered under Medicare. Infertility is a condition sufficiently at variance with the usual state of health to make it appropriate for a person who normally is expected to be fertile to seek medical consultation and treatment.

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Medicare payment for lab cpt code 83036 - important points to consider

Medicare Payment for Clinical Laboratory Services

Before Medicare pays for any test or diagnostic service, two basic criteria must be met:
(1) the service must be covered by Medicare (e.g., certain procedures such as
routine screening tests are not covered) and
(2) the service must be medically necessary or indicated.

Once these two criteria are met, Medicare pays for most clinical laboratory tests based on
the Laboratory Fee Schedule. Each carrier publishes a unique laboratory fee schedule and
adjusts payment levels annually on January 1st based on Congressional budget
recommendation.

Medicare payment for clinical laboratory tests is always the lesser of the fee schedule
amount or the actual amount billed. The provider must accept the Medicare reimbursement
as payment in full for a laboratory test. Medicare patients may NOT be billed for any
additional amounts. Tests must be billed directly to Medicare by the laboratory or physician
performing the test. If an outside laboratory performs a test on a referral from a physician,
only the reference laboratory may legally bill Medicare for the procedure.
Procedure (CPT) Codes and Modifiers

The CPT codes for Glycated Hemogobin (A1c) determinations are:
83036 Hemoglobin; glycated (A1c)
83036QW Hemoglobin; glycated (A1c) using CLIA waived method

Medicare reimbursement for CPT codes 83036 and 83036QW is $13.42 in all states
except:
Idaho: $9.66 Maryland: $12.66 Oklahoma: $11.95
Rhode Island: $12.09 South Dakota: $12.86 Wyoming: $10.49

Diagnosis (ICD-9) Codes
An appropriate diagnosis (ICD-9) code (or narrative description) must be indicated for each
service or supply billed under Medicare Part B. ICD-9-CM is an acronym for International
Classification of Diseases, 9th Revision, Clinical Modification.

When a patient presents with an undiagnosed illness, the ICD-9 code is determined by the
"signs and symptoms" present. Symptoms are defined as what the patient tells the
physician. Signs are what the physician observes as part of his examination of the patient.
Definitive ICD-9 codes should only be assigned and recorded in the medical record after a
diagnosis is clearly determined. Terms such as "rule out", "probable", and "suspected"
should NOT be used since they can not be coded as such and may be interpreted as a firm
diagnosis by a third party payer.

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observation CPT code 99217 - 99220, 99234 - 99236 - HOw to bill

Hospital Observation Services 99217-99220 and 99234-99236

Placement in observation status requires an order from a provider with admitting privileges.  Patients are in observation to determine whether the patient should be admitted to the hospital, transferred to another facility, or sent home.

When there is a three-day observation period, the middle day is coded with an established outpatient visit code, 99211-99215 based on the documentation.

The following services are not covered as outpatient observation services:
•    Observation services that exceed 24 hours unless an exception is deemed necessary following a medical necessity review. 
•    Services that are not reasonable or necessary for the diagnosis or treatment of the patient but are provided for the convenience of the patient, his or her family, or a physician/provider (e.g., following an uncomplicated treatment or procedure; physician/provider busy when patient is physically ready for discharge; patient awaiting placement in a long-term care facility).
•    Inpatient services.
•    Services associated with ambulatory procedure visits.
•    Routine preparation services furnished prior to the testing and recovery afterwards (e.g., patients undergoing diagnostic testing in a hospital outpatient department).
•    Observation concurrent with treatments such as chemotherapy.
•    Services for postoperative monitoring.
•    Any substitution of an outpatient observation service for a medically appropriate inpatient admission.
•    Services that were ordered as inpatient services by the admitting physician/provider but reported as outpatient observation services by the hospital.
•    Standing orders for observation following outpatient services.
•    Discharges to outpatient observation status after an inpatient hospital admission.

When a patient is admitted from observation status, the ADM record for the observation care should be closed out with a disposition type of “admitted.” 

When a patient is referred from observation to an ambulatory procedure unit (APU) or another MTF, the ADM record for the observation care is closed out with disposition type of “immediate referral.” 

E&M codes will be used to document the length and acuity of observation care services in ADM.  Observation E&M codes relate to the number of calendar days (dates) the patient spends in observation status and the acuity of the stay.

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Understanding CPT Code 28510 – Billing for Fracture Care Follow-Ups

With regards to Standard Fracture Care, a patient’s fracture follow-up can be billed by the doctor.  The doctor must make sure, however, that the appropriate procedure codes as well as the ICD-9 code is used.  This pertains to the site of the fracture.  The follow-up care for closed fracture sites are covered by the CPT code 28510.  All, except those that involve the big toe.  Due to the details enclosed in this code, the need to perform site manipulations is no longer required if you plan to bill a patient’s follow-up care.  Because of the code 28510, it is immediately expected that a doctor will earn a hundred dollars for each patient.

A patient who comes in for a follow-up with regards to an injury such as a fracture is expected to spend time in a doctor’s clinic.  There is also a big possibility for them to inform you about certain medical issues they might have that would not be related to their fracture.  Doctors would not have to worry when this type of situation arises especially if they did not provide the fracture care initially.  As long as you document the visit correctly, you would be able to bill for the fracture follow-up and the additional concerns separately.  This is justified by the fact that the other concerns are not in any way related to the fracture.  The doctor just has to be very detailed about the consultation with regards to the proper procedure codes and the injuries addressed.

If ever the situation involves a patient who has multiple fractures comes for a follow-up, you can bill for each type of fracture.  For example, a patient has a fracture in his ribs, legs, and arms.  You can bill each site separately.  It is, however, crucial to document each fracture addressed and how long it took you to address it. 

Most fractures are billed to insurance companies of patients.  There are cases, however, wherein their fracture is work-related.  With this situation, Worker’s Compensation and the Personal Injury Protection Policy are applied.  The guidelines with this type of insurance may vary from state to state so it is important for a doctor to know about them before applying codes for the follow-up and any procedures done on the patient.  The important thing here is that the doctor gets paid for the care he has provided for the patient even if the initial check was done by another doctor.

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PSYCHCARE TRIAGE AND REFERRAL PROCESSES

Our  clinical  philosophy  is  to  provide  the  most  appropriate  member/practitioner  match  and  the  least  restrictive treatment intervention for each member's needs across the life cycle. Our clinical orientation is a biopsychosocial approach  with  emphasis  on  wellness,  early  intervention,  and  integration  of  behavioral  and  medical  healthcare. Excellent outcomes are maximized by good partnerships and a clinical consultation approach with all clinicians that deliver services to our members.

Psychcare  makes  decisions  whether  to  approve  or  not  approve  payment  for  services  based  only  on  the appropriateness of the care or service, and what the member’s benefit plan covers. 

The Medical Director oversees all triage and referral decisions. The Medical Director is available 24 hours per day; 7 days per week, to consult on initial clinical review decisions, and conduct peer clinical review. 

The Vice President of Clinical Operations supervises nonurgent pre-service processes, and initial clinical review processes. The Vice President of Clinical Operations is available 24 hours per day, 7 days per week, to consult with Case Managers on initial clinical review decisions 


Emergency Referrals 

In the event a patient is experiencing a behavioral health emergency in your office, or contacts you in crisis, call the police. If your patient can be safely transported with support, route the member to the nearest emergency room. After ensuring that the patient is safe, call Psychcare 24 hours per day, 7 days a week at (800) 221-5487 so that we can obtain the clinical information and begin managing the case. 

If you call after hours or on the weekend, please inform the answering service that you have an emergency and the on-call case manager, a licensed clinician, will return your call within 30 minutes of the initial call. The on-call case manager arranges hospital admissions, crisis stabilization, and other required emergency services.

Initial Referral Process 

Psychcare preauthorizes, and coordinates initial evaluations with our network psychiatrists and clinicians. 

During  the  course  of  your  patients’  medical  treatment,  you  may  determine  that  the  patient  could  benefit  from accessing their behavioral healthcare benefits when, for instance:

** the member requires an assessment of their current psychotropic medication(s), or an evaluation to determine the need for psychotropic medication  
** the member is experiencing an acute crisis and needs to be evaluated by a psychiatrist
** the member is experiencing stressors that could possibly be reduced through psychotherapy

When  callers  request  routine  outpatient  referrals,  the  calls  are  handled  by  our  intake  coordinators.  The  intake coordinator verifies the member’s eligibility and demographic information. They conduct a brief screening using an approved  screening  tool.  During  the  screening,  if,  as  indicated  per  the  screening  tool,  the  call  requires  clinical expertise, the intake coordinator transfers the call to a case manager. Once the intake coordinator completes the
screening,  the  member  is  given  the  names  of  network  practitioners  who  meet  their  geographic,  language,  and cultural preferences. The member selects the practitioner they wish to see and the intake coordinator authorizes the members’ outpatient visit. 

If you would like refer a patient to Psychcare for mental health or substance abuse treatment, simply fax a referral to  Psychcare  to  (800)  370-1116,  or  call  us  to  coordinate  the  referral  at  (800)  221-5487  during  business  hours, Monday  through  Friday  8:30  AM  to  5:30  PM  EST.  Please  include  all  pertinent  clinical  information  and  member contact information. 

Continued Treatment 

All  urgent  care  and  continued  treatment  are  reviewed  by  case  managers.  Case  Managers  are,  at  a  minimum, Masters’  Level  Licensed  Clinicians,  or  Registered  Nurses,  with  a  minimum  of  5  years  experience  post  master and/or previous experience in providing direct patient care, crisis intervention and discharge planning. The case managers  review  the  continued  treatment  at  pre-determined  intervals  with  the  psychiatrist,  clinician,  hospital,  or program.  Ongoing  authorization  is  based  on,  as  applicable  to  the  individual  status  of  the  member,  Psychcare
Mental  Health  Level  of  Care  Clinical  Criteria,  Psychcare  Substance  Abuse  Level  of  Care  Criteria  or  Florida Medicaid Level of Care Guidelines and the member’s benefit coverage.

In particular, cases, care may be required outside of the usual parameters set forth by the member’s benefit plan. In such cases, the Medical Director and the Vice President of Clinical Operations may work with the case manager and the practitioner to develop an appropriate treatment care plan.

Specialized Services Requirements  

The following services are authorized only when they are determined to be medically necessary, and inclusive in the member’s benefit coverage. The case manager consults with the Medical Director when the following services are requested, and covered under the member’s benefit plan:

** psychological testing
** electroconvulsive therapy (ECT) 

The following services are typically not covered under a typical benefit plan:

** marital counseling
** testing for educational placement
** neuropsychological testing  

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