Self's Tips And Tidings by tX5tJ7


									                        Don Self & Associates, Inc.
                            Don Self, CSS, BFMA
                        305 Senter Avenue,       Whitehouse, TX 75791
                            903 839-7045         Fax 903 839-7069
                      WWW.DONSELF.COM           DONSELF@DONSELF.COM

                RULE CHANGE
In the past few issues, we’ve notified you that the 1997 regulations required certain changes and
one of those changes was going to have a NEGATIVE impact on most primary care, pain
management, occupational, physiology and orthopedic practices. That change mandated that
patients receiving physical medicine services must have CONSTANT attendance by the physician,
physical therapist or someone that had completed the PT curriculum.

In last month’s issue, we told you that the June 6 mandate from Medicare indefinitely delayed the
implementation of this rule. As President Reagan would say: “Welllllll,” that has been reinstated as
of July 26 – so the new rule is in effect. This means that if you are going to bill for codes 97001
through 97542, you are required to have the service directly provided by either the physician, mid
level (NP or PA), PT or someone who has completed the PT curriculum. No longer will the
physician be able to just order the service and have the MA or nurse hook up the patient to the
physical medicine modality and check in occasionally on the Medicare patient.

This does NOT affect the non Medicare patient, as you can continue to render the service to them in
the same manner you have always done.

We are in the process of trying to set up a locator service for licensed and unlicensed PT’s all over
the country, with the idea that physicians can continue to render the services as usual, MOST of the
time, but when they want to render physical medicine services to Medicare patients, to schedule
them on a certain date and hire a PT to come in on a contractual basis for that day to render the
service to the Medicare patients. While this may reduce the profitability for some of the services to
Medicare patients, it will still allow the physician or practice to be able to render the services to
Medicare patients – rather than have to refer the patients to another practice. We would love to get
your viewpoint on this possible new service we may offer, whether you think it is worthwhile or a
waste of time.

   I Work Hard Because Millions On Welfare Depend on Me!
         I used to have a handle on life, but it broke.
      NyQuil, the stuffy, sneezy, why-the-heck-is-the-
                  room-spinning medicine
     There are correct and incorrect ways to divorce your patient. The incorrect way is to send
     the patient a CD with the song 50 Ways To Leave Your Lover to your patients. Yes –
     there are times when it is necessary and appropriate to divorce your patients, including
     some of the following:
         The patient refuses to follow your instructions for care or tests,
         The patient fails to keep appointments,
         The patient is rude to your staff,
         The patient doesn’t pay their bill or pay the co-pay at the time of service,
         The patient refuses to bathe for days before each office visit,
         The patient is simply a drug seeker

     So, now you’ve decided that you want to divorce the patient, so what is your next step?
     It’s really quite simple. Notify the patient of your intention and follow your state law. You
     are within your rights to terminate a physician-patient relationship for any reason YOU
     choose, but you do have certain legal responsibilities in this area.

       Statutory laws vary from state to state and create complexity to the common-law rules.
                of those laws include those governing emergency treatment provided
       (EMTALA, the Emergency Medical Treatment and Labor Act) and antidiscrimination
       statutes, as well as certain ethic I’m constantly amazed by state medical ethics
In every seminar I teach around the country, constraints mandated at how many offices are
NOT committee’s. (Note – EMTALA affects hospitals and not private physician offices). their
         billing for the interpretations and reports the physicians are performing on
patients in the ER and in the hospital. How many times does your physician get called to
       Withdrawal from EKG or x-ray should not be attempted or that during a time when
the ER and order an the relationshipon the patient and then use done interpretation of the the
       patient is to determine a course of treatment on the very broad terms, you can or
diagnostic tool in need of medical attention. Otherwise, inpatient? If your doctor writeslegally
       terminate your relationship with patient if you:
dictates the interpretation and reportafor the patient’s chart, does your physician report this
          Give to patient
billable servicethe you? adequate notice in writing, preferably by certified mail, return receipt
         requested (30 days is a good rule of thumb).
             Give the preach in seminars, Medicare ruled back in December 1995 that the
As weconstantly patient a brief explanation of why you are terminating the relationship. Be
         absolutely certain that EKG to make a could not decision can and should bill for
physician using the x-ray or the reason given treatment be a pretext for discrimination. the
          Document notification and Yes – we are fully aware that hospitals require an over-
service to the patient or insurance. the reasons for termination in the patient's medical record.
          Help the strip due to JCAHO standards, but that is not considered reimbursable by
read of the film or patient find another physician. Generally this can entail giving the patient the
Medicare. number of the local medical society or a physician referral service.
          Offer to transfer medical records to a newly designated physician upon receiving
         signed “Then, why does Medicare
You may askpatient authorization to do the Radiologist or Cardiologist for it?” The
          Continue Because urgent for it and Medicare the patient to pay in need of care.
answer is simple. to providethey billor emergency care ifis expectingremainssomeone for it,
so they issue a check to the party that bills for it. Remember – Medicare will pay the first
       It's also advisable to check with your malpractice carrier, particularly if you're in the middle
claim the receive for the interpretation – so if YOUR doctor is the one providing the medical
       of a course of treatment, and check with payers to make sure you're not in violation of your
treatment based on the results and your doctor documents the interpretation (more than just
a single line saying there doesn’t appear to be any cracks in the bone), then you should bill
for the interp and get the claim in quick.
                              AMAZINGLY SIMPLE HOME REMEDIES
Now –Ifis this going to on an ice cube, don'tat the Simply pour awith of boiling water down your
     1.     you are choking be popular news panic. hospital or cup your local Radiologist or
Cardiologist? Nope – not at all. I have be almostbeen cussed by a Radiologist at a seminar
          throat and presto. The blockage will actually instantly removed.
     2. told the primary care docs while for what services they are rendering. to we
when IClumsy? Avoid cutting yourselfto bill slicing vegetables by getting someone elseAs holdhave
alwaysthem while you chop away. bill for what services you are rendering that is medically
           promoted, you need to
     3. For
necessary.high blood pressure sufferers: simply cut yourself and bleed for A few minutes, thus
       reducing the pressure in your veins. Remember to Use a timer.
    4. A mouse trap, placed on top of your the clock, primary care office. You will sleep
This change will not make you rich, inalarm typicalwill prevent you from going back to find the
       after you hit the snooze Button.
Medicare reimbursement range from $9 to $13 per EKG interp and $15 to $21 2005 most x-
         1-800-256-7045                    Page   2                      AUGUST for
ray 5. If you have a bad cough, The important of laxativesget into the habit refusing to what
    interps – but they add up. taking a dose thing is to will result in you of billing for
you do.cough.
1-800-256-7045   Page   3   AUGUST 2005
                       PAPS, PELVIC AND FECAL TESTS
 Q0091 Obtaining the Pap Smear
 G0101 Breast & Pelvic Exam (need 7 of the 11 elements identified by CMS)
 G0107 Fecal Occult Blood Test

 DX: Pap/Breast & Pelvic Exam use appropriate HCPCS code V72.31 (as of July 5, 2005), V76.2, V76.47
 &/or V76.49 (or for High Risk V15.89). For FOBT use V76.51 &/or V76.41.

 If a complete physical was done, use one of the Preventive med codes; however, Medicare does not cover
 these and the covered services need to be carved out of the Preventive Medicine charge, which reduces the
 patient's out-of-pocket responsibility. Generally, we recommend you NOT roll a preventive medicine visit
 into a sick visit and if the patient presents during a physical with a problem, to reschedule the annual or
 preventive visit instead of trying to do both at one session.

 Medicare covers Pap & Pelvic Exams once every 24 months. However, they are covered once every 12
 months if the woman is at high risk for cervical or vaginal cancer, or if childbearing age. or has had an
 abnormal Pap test in the past 36 months. For patients who are on the 24 month frequency for covered pap
 smears, no ABN is necessary. If a patient chooses to have a pap yearly, the patient will need an ABN for
 the alternate year because an ABN is necessary for services that are outside the frequency limitation.

 Medicare has developed an excellent Preventive Medicine website at:

How many times have you received a refund request from an insurance carrier a year or
two after they had processed the claim? Some states have limits on carriers and plans for
how long they can either retroactively deny or recoup on claims. For instance, in Texas,

Section 3A(h) of Texas SB 418 says, "The insurer must complete the audit on
or before the 180th day after the date the clean claim is received by the
insurer, and any additional payment due a preferred provider or any refund
due the insurer shall be made not later than the 30th day after the
completion of the audit."

Not all states have these kinds of laws – but most do. You can find out if your state has one
or not, by calling your state board of insurance office and simply asking them. If your state
does not have one, then it’s up to you (yes – I’m pointing at YOU!) to get one passed. It’s
not difficult – but it does require action on your part. You need to contact your state
legislator (invite them to lunch sometime and remember – they work for you) and explain
you need a law like Texas has. Hand them this newsletter and ask them to get it passed
within the next few months. Let them know that you will get a few of your friends to help put
the word out to about 3 or 4 million voters in the next few months when they have a bill
drafted and a number assigned to it. Then – email a few of your friends (contact your state
osteopathic or medical assn), give them a letter to send out to every doc in your state that
the docs hand to the patients in the reception area. The patients sign that letter and mail it
to their own legislator and pretty soon… it’s law. There is only one reason why it won’t work
and that is due to the fact that someone is too lazy to do these things…. That’s not you, of

      1-800-256-7045                            Page     4                       AUGUST 2005
         (Unless you want to increase your monthly collections)
Awhile back, I heard of a doctor who refused to accept credit cards in his practice as he
did not want to have to pay the 3% (or whatever) that his bank was charging him. He
did choose to accept checks and did receive insufficient funds checks about once or
twice a week.       This man may have been an excellent physician, clinician and
diagnostician – but he was a lousy businessman with this kind of policy in his practice!

I would GLADLY pay 3% to 4% on credit card charges I deposit, rather than have to
send monthly statements, mess with returned insufficient fund checks and pursuing
collections from my patients. It just makes good business sense!

I’ve heard of one physician who had an ATM machine installed in his office and the
patients would have to pay the ATM fee to get cash out of it, so they could pay their co-
pays.     Yes – it is legal to have the patient go get cash to cover co-pays and
deductibles in a physician office. In fact, when you explain to the patient that the doctor
is running a few minutes late and that will give them time to go down the street to the
convenience store to get cash out of an ATM, go ahead and ask them to pick you up a
Dr Pepper at the same time… Patients don’t mind and if they do…. too bad!

Wrinkled Was Not One of the Things I Wanted to Be
               When I Grew up!


                              SKIP TRACING?
   If you’re trying to locate some patients who may have skipped out on a past due
 balance, check out ACCUINT as their service is recommended by one of our clients.
  They are at and we’re told they are only 25 cents per address.

 Clumsy? Avoid cutting yourself while slicing vegetables by getting
        someone else to hold them while you chop away

  MEDICARE SAYS …. It is legitimate to charge fees for non-covered
   services, e.g., work related forms, camp examinations, travel visa
 1-800-256-7045 and the like. A physician may not charge patients for
                                Page 5                 AUGUST 2005
                              completing claims.
                    DIABETES SCREENING CODES
You can now bill the Medicare program twice a year for “pre-diabetic” patients
(fasting glucose levels of 100 – 125) per Medicare. You can bill once a year for
these tests for those that do not meet the twice a year requirements.

Codes 82947, 82950 and 82951 are for the glucose tests and may be billed in
addition to covered office visits – plus the venipuncture.

82947 Glucose, quant., blood (except strip)       Average Medicare payment $5.48
82950 Post-glucose dose                            Average Medicare payment $6.64
82951 Glucose Tolerance Test (GTT), three specimens Avg Medicare payment $17.99

                      MODIFIER 25 OR 59?
This subject (modifier 25 and it's usage and when it's appropriate compared to 59) comes
up quite often on almost every listserv. I've never seen a definitive answer from an official
source (or at least one that I trust) on this - but for the sake of the discussion, I'll toss out
why I believe 25 should not be used for multiple E&Ms on one day.

In order to do so - let's back up just a little and discuss when the majority of insurance
carriers (including Medicare) wants us to use 25 modifier. Yes, yes, yes - we all know the
"significant, separately, identifiable, blah blah blah". That's not what I mean. For instance,
do you need to use a 25 modifier on the visit when you also do a regular IM injection
(90782)? No - because 90782 has a designation of XXX in the global fee periods listed by
Medicare - meaning that it has no global fee period and nothing else is bundled into it. The
same thing goes for an office visit and an EKG (EKG has XXX). Yes - you need it if the
procedure has a 000 or 010 as a designation for global fee because anything else done the
same day is bundled into the procedure. In that instance, you need a 25 on the visit code if
the doc does an office visit and determines that a joint injection into the knee (20610) is
warranted, since 20610 has a 000 global fee period (For those unfamiliar with these - yes
you can download them on my website and don't confuse 000 as meaning no global period
- which is incorrect. 000 means no ADDITIONAL days are included in the global - but the
day of the service, any E&M is bundled without the proper modifier). The same thing
applies with cerumen removal (69210) or lesion removal (17000 and 17003), etc...

So - we've established, through normal coding custom, that we need to use the 25 modifier
on the visit code when the other service has a global fee period - but we do not need it
when the other service has no global (XXX), right?

So - my thoughts are that we do not need the 25 modifier when we do 2 E&M visits on the
same day since all E&M visits have XXX global fee period. That leaves us with the
question "How do we keep the carrier from bundling or assigning "duplicate" to the 2nd
E&M? To me, the answer is obvious. You tell them that each E&M is DISTINCT (modifier

   1-800-256-7045                         Page    6                          AUGUST 2005
 Instead of the 4.3% projected reduction in Medicare allowed amounts in 2006, we may
 see a 2.7% increase, if legislation being drafted by a Connecticut representative gets
 approved. Nancy Johnson (R) is the chairwoman of the House Ways and Means Health
 subcommittee and is trying to replace the current payment update formula. If she is
 successful, you will see an increase in 2006 instead of a decrease. Now would be a great
 time for you to call your U.S. Representative and ask them to support Ms Johnson’s bill.
 That one letter from you to them may increase your income by thousands next year.

  The answer of how to bill for sports physicals depends on whom you ask. Some people
  promote the idea of using preventive medicine codes while others like the idea of using
  office visit codes 99201 – 99215. The debate will rage as to whether the annual
  preventive code is much more comprehensive than the routine “Can I play baseball on my
  school team?” exam, or what code do we use to FORCE the insurance carrier to cover
  something they said they don’t want to cover.

  Being on about 14 different internet listservs (also known as email chat rooms) ranging
  from specialties like Family Practice, Internal Medicine, Cardiology, Pain Management,
  Part B, Coding&Reimbursement, Gastroenterology, Neurology, Podiatry, etc…, we see
  the same questions come through over and over. This is one of the recurring questions.

  We do not EVER believe you should be billing the insurance carrier for a simple sports
  physical, as NONE of the CPT codes describes this brief, non-illness-related visit. We
  recommend you make the patient’s family pay cash for the visit and if they want a receipt
  with a code on it – use the code SPORT (five digits so it will fit in your computer system).
  Here is a piece of advice we saw from Becky Swank on a Family Practice listserv. She
  uses the following:

  9939X – well child with incidental sports physical
  9921X – problem found at time of sports physical
  99080 - only forms filled out – perhaps well child exam recently

  If it’s simply a sports physical (Can I play full contact badminton?), we recommend you
  use SPORT as your code and collect the cash. If it falls into the other categories shown
  above – use one of those codes. Good luck

        1-800-256-7045          HOSPICE MODIFIERS
                                      Page 7                                AUGUST 2005
        Whatever to the hospice patient's terminal condition
"GW" - Service not relatedhappened to Preparations A through G?
 "GV" - Attending physician not employed or paid under agreement by the patient's hospice provider.
We now offer seven different products to physicians that will help their patients and increase practice
revenue. Not only do these have positive results with the patients (sometimes to the point where the
physicians do not believe us until they see results within one week on their own patients), but the
profit potential for the physicians is fantastic.

In fact, last month we opened a new company called PMCA (Practice Management Consultants of
America) along with nationally known Pain Management consultant Trish Bukauskas-Vollmer. Not
only are we consulting nationwide with physicians and clinics, but we now are going to be at 40
conventions a year with our exhibit booths. If you have a convention that you think we should be at
– please let us know.

                            7 DAY CRUISE NEXT FEBRUARY
We should have word within the next week or so with the details of the 7 day cruise
from New Orleans to Honduras, Belize and Cozumel in conjunction with the Mississippi
Osteopathic Medical Association. There will be CMEs, CEUs, education, and fun. If you
want us to get you info on this (within the next 2 weeks), please call 800 256-7045 or
email us quickly.

          305 SENTER AVE.
       WHITEHOUSE, TX 75791


           1-800-256-7045                     Page   8                      AUGUST 2005

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