Updates on Referrals, Prolonged Services, and Billing Medigap Plans
When it comes to receiving timely and appropriate reimbursement, details matter. Here's an update on three areas of billing that warrant attention.
By Sharon Andrews, RN, CCS-P

Next month (October 5), Medicare will begin auditing claims for services that have been ordered or referred. Auditors will validate the ordering or referring provider's name and NPI against Medicare's provider enrollment records to ensure that the referring or ordering provider is enrolled in Medicare and is from a specialty eligible to refer. MDs, DOs, PAs, and NPs are all eligible to refer.

Initially, when errors are found, the claim will still be processed; Medicare will advise the practice of the error with a message on the EOB. After a period yet to be announced, claims that do not have the correct information will be denied. With audits looming, now is a good time to make certain that your practice has the correct NPIs of referring providers and that you provide your correct NPI when you order or refer a service.

Any provider who has moved since obtaining an NPI must be sure to update his or her information with the National Plan and Provider Enumeration System (NPPES). HIPAA requires that providers update information within 30 days of any changes. Many physicians received their NPIs because of the efforts of someone in their MD, DO, or residency programs. If this is the case with your NPI, it is necessary to update the information when leaving the institution. For assistance, call 800-465-3203, or go to the website at https://nppes.cms.hhs.gov/NPPES/Welcome.do.

SIGNATURE ON FILE
"Signature on file" is the term applied to insurance claims to indicate that the patient has signed a form authorizing the practice to file claims and be paid on his or her behalf. Many practices do not properly acquire signatures, because they often fail to obtain signatures authorizing billing of Medigap plans. When a patient has both Medicare and a Medigap plan, there must be a separate signature on file for the Medigap assignment, and it must be insurer specific. Make sure your practice uses a form that requires separate signatures for Medicare and Medigap and that the Medigap carrier is identified.

PROLONGED SERVICES, 99354-99357
Modifier 21, Prolonged services, has been deleted from CPT as of the 2009 edition, but payment for prolonged services is still available. If at least 50 percent of the visit is spent counseling the patient, the E/M codes 99201-99215 and 99241-99245 can be used, and are selected according to total time spent with the patient. If a provider must account for more time than allowed by 99205, 99215, or 99245 or the 50 percent rule is not met, prolonged service codes 99354-99355 may be added to the appropriate E/M code. If the prolonged service is less than 30 minutes beyond the E/M service coded, a prolonged service code is not billed. Codes 99354-99355 require direct physician face-to-face time with the patient on the same day, but the time spent does not have to be continuous. 99354 and 99355 are used in the office, home, domiciliary home, and outpatient psychiatric facilities. 99355 and 99356 are used for inpatient facilities.