SBCMS News/Media

Coding Corner: Physician/patient meet-and-greet

CPR’s “Coding Corner” focuses on coding, compliance, and documentation issues relating specifically to physician billing. This month’s tip comes from G. John Verhovshek, the managing editor for AAPC, a training and credentialing association for the business side of health care.

Potential patients sometimes ask to meet with a provider prior to needing health care to be sure that the patient/provider relationship will be a good fit. For example, it’s common for expectant parents to “interview” obstetricians and pediatricians.

The reality is, time equals money, and physicians’ time is in demand. As such, practices may wonder if it’s possible to bill for such meet and greet visits. The answer is yes, but you probably won’t want to.

Without Medical Necessity, Insurers Won’t Pay

To be clear, you shouldn’t bill a meet and greet visit to a patient’s insurer.

Insurers, including government payors such as Medicare and Medicaid, reimburse only those services or procedures that they deem to be medically necessary—and a meet and greet doesn’t meet the definition. The individual meeting with the provider may be a potential patient, but if there’s no medical reason for the visit, the insurer isn’t going to treat the claim as legitimate.

You cannot report evaluation and management (E/M) service codes for a meet and greet because E/M services require a chief complaint, defined by CPT® as “a concise statement describing the symptom, problem, condition, diagnosis, or other factor that is the reason for the encounter, usually stated in the patient’s words.” Again, if there’s no medical reason for the visit, there’s no medical care to report.

Preventive services don’t require a chief complaint, insurers often reimburse for them, and CPT® designates a subsection of E/M codes to report them. But, a meet and greet visit won’t include the age and gender appropriate history, examination, counseling, anticipatory guidance and other required components of a preventive service.

ICD-10 does provide codes to describe meet and greet visits, for instance, Z76.81 Expectant parent(s) prebirth pediatrician visit. ICD-10 is a very thorough code set to allow for precise, wide-ranging data collection, but the existence of an ICD-10 code has no connection to medical necessity and doesn’t guarantee payment.

The bottom line is this: Billing any type of E/M service code for meet and greet visits is inappropriate, potentially abusive and fraudulent.

Billing the Patient for “Non-Medical” Services

Just because you provide a non-medical service doesn’t mean you can’t bill for it. For example, offices routinely charge for services such as filling out forms—for schools, sports, life insurance, medical leave, etc.—that are not connected to a patient visit, or for copies of medical records (states typically regulate how much you may charge to copy medical records).

Similarly, you could charge patients directly for meet and greet sessions. Before doing so, however, there are a few things to consider.

First, you have to acknowledge that charging for a physician meet and greet might turn off potential patients before you even get them in the door. Providers benefit from positive relationships with their patients, which makes charging for meet-and-greet style visits an especially difficult proposition.

Second, if you decide that charging for a meet and greet is worth the effort, you should be sure to establish a written policy, alert potential patients to it ahead of time, and follow it consistently. Patients should know how much they will be charged, and how and when they should pay (unless you collect “up front,” you’re unlikely to collect, ever). You should be clear that insurance won’t cover the service, and that you will not file a claim on their behalf.

Note: The above information does not constitute, and is not a substitute for, legal or other professional advice. Readers should consult their own legal and other professional advisors as necessary for individualized guidance with respect to each particular situation.

Anthem issues new ID number for some patients

Anthem Blue Cross has issued new identification numbers and cards for a number of its members. New ID cards containing the new ID number were mailed to all affected members in late December. Providers are encouraged to make copies of each patient’s insurance card at the time of visit to verify the member’s identification number.

Anthem advises that claims submitted with an incorrect ID number will be returned to the provider for correction and resubmission with the correct ID. Providers will need to contact their patients to obtain their updated identification number. If a member does not recall receiving a new ID card in December or misplaced an ID card, the member can contact Anthem to verify their ID using one of the following options:

• Call the Anthem member services number on their ID card
• Log into their member account at www.anthem.com/ca
• Use Anthem's mobile app (Anthem Anywhere) to access their electronic ID card

DHCS loads 2019 CPT Codes and Pricing by January 1

The California Department of Health Care Services (DHCS) has confirmed that the 2019 CPT/HCPCS updates have been loaded to the Medi-Cal system and were effective January 1, 2019. 

Every year, the Centers for Medicare and Medicaid Services (CMS) issues new, updated and terminated CPT and HCPCS codes. However, in past years it has taken DHCS up to 10 months to update its system with the new or updated codes and pricing. This has caused unnecessary delays and denials in payment not only on Medi-Cal fee-for-service claims, but also for many Medi-Cal managed care claims, as the plans follow Medi-Cal payment rules.

DHCS has committed to making these changes by January 1 each year going forward, to prevent these delays and denials. This is a welcome change for which the California Medical Association has been advocating. CMA applauds this action by DHCS, as it will ensure affected claims are paid correctly and in a timely manner.  The January 1 effective date will mirror the implementation date applied by all other payors and avoid these delays and improper denials caused.

The Medi-Cal reimbursement rates page has also been updated to reflect pricing for the new codes.

Medi-Cal provider enrollment moving exclusively to PAVE starting March 5

The Medi-Cal Provider Enrollment Division (PED) recently announced that it will no longer accept paper enrollment forms, effective March 5, 2019. Medi-Cal enrollment applications and forms will move entirely to the e-form application process through the California Department of Health Care Services’ (DHCS) Provider Application and Validation for Enrollment (PAVE) portal.  While PAVE was anticipated to eventually replace the paper application process, DHCS moved swiftly to eliminate the paper option for providers after the September PAVE update (3.0).

Prior to the announcement, PED did seek feedback from stakeholders including the California Medical Association (CMA). Based on that feedback, agreed to expand the notice period of this change from 30 days to 60 days. It is also offering additional PAVE training to ensure users are prepared to begin using the online enrollment process.

CMA also urged PED to allow an exception for those doctors who still wanted to submit paper applications. To request an exception, submit the request in writing to:

Department of Health Care Services
Provider Enrollment Division
MS 4704
P. O. Box 997412
Sacramento, CA  95899-7412

The request should include a detailed explanation why they cannot use PAVE and include any supporting documentation. PED will review these requests on a case by case basis to determine if an exemption should be granted. 

The PAVE system, initially launched on November 18, 2016, transformed Medi-Cal  provider enrollment from a manual paper-based process to a web-based portal that providers could use to complete and submit their applications and verifications, and to report changes. 

According to DHCS, the process for completing an application through the PAVE system is dramatically streamlined, dropping the average to complete an application from 1.75 hours to 0.7 hours. DHCS also reports its average provider application processing time has dropped from an average of 75 days to 59 days, with the goal to eventually achieve a 30-day turnaround timeframe. 

For more information about PAVE, see the DHCS PAVE FAQ.

Golden Shore Medical Group to shut down following Molina contract termination

The California Medical Association (CMA) has learned that Molina Healthcare has terminated its contract with Golden Shore Medical Group. The plan filed requests in late 2018 with the California Department of Managed Health Care (DMHC) to transfer its enrollees to other delegated groups and the request was approved by the Department on January 11, 2019.

According to Molina’s block transfer filing with DMHC, the termination was the result of the parties’ inability to agree on contractual terms. As a result of the termination, Golden Shore has announced to its network physicians that it will close its doors on January 31, 2019.

The plan filings with DMHC indicate approximately 80,000 Molina enrollees, 94 percent of which are Medi-Cal patients, will be affected in Sacramento, San Bernardino, Riverside, Orange and Los Angeles counties as follows:

*Note: there are approximately 26 receiving medical groups/IPAs. Those listed represent medical groups/IPAs that will receive 200 or more enrollees.

The plan filing indicates that only nine percent of enrollees are expected to be able to retain their current primary care physician.

Four other plans also delegated a small number of enrollees to Golden Shore—Brand New Day, Central Health Plan, Easy Choice and Aetna. CMA is gathering more information on the total number of enrollees with these four plans and which delegated groups will receive the enrollees.

Claims for services provided through January 31 should be submitted to Golden Shore for payment. If claims have been submitted to Golden Shore and are not being paid timely, physicians should contact the plan directly.

CMA encourages physicians to be diligent in obtaining updated insurance information from Golden Shore patients and to verify eligibility at the time of scheduling, if possible, to avoid unnecessary patient confusion and denials of payment for services rendered.

Patients may also be able to continue to see their physicians, even if they the physician is not contracted with the patient’s new delegated entity, under California’s continuity of care law. Under continuity of care laws, patients with an acute condition, serious chronic condition, duration of a pregnancy, duration of a terminal illness, and care of children between birth and 36 months may qualify to request continuity of care. Additionally, patients that have received an authorization for a surgery or other procedure to be performed within 180 calendar days of January 31, may be eligible to request continuity of care. To request continuity of care, patients should call the health plan number on the back of their ID cards.

For more information on continuity of care requirements, see CMA health law library document #7051, “Contract Termination By Physicians and Continuity of Care Provisions.” (Health law documents are available free to CMA members. Nonmembers can purchase documents for $2 per page.)

CMA will provide more information on Molina’s transition once we received updated information on the receiving groups. Practices that are experiencing problems with Golden Shore or issues resulting from the contract termination are encouraged to contact CMA’s Reimbursement Helpline at (888) 401-5911 or economicservices@cmadocs.org.

CMA's online health law library is free to members

The California Medical Association (CMA) online health law library contains nearly 5,000 pages of up-to-date legal information on a variety of subjects of everyday importance to practicing physicians. One of CMA's most valuable member benefits, the searchable online library contains all the information available in the California Physician's Legal Handbook (CPLH), an annual publication from CMA's Center for Legal Affairs.

CMA members can access the library documents free at cmadocs.org/health-law-library. Nonmembers can purchase documents for $2 per page.

CPLH, the complete health law library, is also available for purchase in a multi-volume print set or annual online subscription service. To order a copy, visit cplh.org or call (800) 882-1262.

CMS completes issuance of new Medicare ID cards

The Centers for Medicare and Medicaid Services (CMS) has now completed the process of mailing new Medicare cards to beneficiaries across all states and territories. The new Medicare ID cards, required under the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), contain a unique, randomly assigned Medicare Beneficiary Identification (MBI) number, which replaces the previous Social Security-based number.

CMS also reports that for the week ending January 11, 2019, fee-for-service health care providers submitted 58 percent of claims with the new MBIs. 

CMS is allowing a 21-month transition period (which began in April 2018), during which health care providers will be able to use either the patient’s current Medicare number or the patient’s new Medicare number for all Medicare transactions. The transition period will end December 31, 2019. While providers can continue submitting claims with the old ID numbers during the transition period, physicians are encouraged to use the new MBIs as soon as possible for all Medicare transactions. 

CMS has developed a webpage to help physicians navigate the MBI transition, including slides from the most recent CMS Open Door Forum on the issue. Physicians are also now able to look up their Medicare patients’ new Medicare numbers through Noridian, the Medicare Administrative Contractor’s, secure web portal. Physicians should also talk to their practice managers and health IT vendors now to ensure their systems are ready to accept the MBI.

If your Medicare patients say they did not get a card, instruct them to:

• Sign into MyMedicare.gov to get their new numbers or print official cards. They need to create an account if they do not already have one.
• Call 1-800-MEDICARE (1-800-633-4227) to get their new cards.  
• Continue to use their current cards to get health care services. They can use their old cards until December 31, 2019.

For more information, please visit cms.gov/newcard.

UnitedHealthcare delays outpatient advanced radiology policy until February 1

Citing the need for additional time for communication and optimal rollout, UnitedHealthcare (UHC) has delayed implementation of its outpatient advanced radiology policy until February 1, 2019. 

The new UHC policy—originally scheduled for implementation on Jan. 1—requires prior authorization for advanced imaging procedures, including certain magnetic resonance imaging, magnetic resonance angiography and computed tomography imaging procedures, when performed in the outpatient hospital setting.  Under UHC’s Outpatient Radiology Notification/Prior Authorization Protocol, a site of care review will be required for these advanced imaging services when performed in the outpatient hospital.

Site of care reviews will not be done as part of the prior authorization process if a procedure will be performed in a free-standing diagnostic radiology center or an office setting. Additionally, authorization will not be required for procedures performed in an emergency room, observation unit, urgent care center or during an inpatient stay.

The UHC policy is similar to a policy implemented by Anthem Blue Cross in December 2017.

For more information on the new policy, UHC has published the Site of Care for Outpatient MR/CT Services FAQ or physicians can visit the Radiology Prior Authorization and Notification page on the UHC website.

The California Medical Association will be closely monitoring this policy as it is implemented to better understand how it will affect physician practices and patient care.

CMA and AMA urge exemptions from Open Payments reporting

The American Medical Association, the California Medical Association (CMA) and more than 80 other health care organizations recently submitted a joint letter in response to a request from the Centers for Medicare and Medicaid Services (CMS) for feedback on the Open Payments Program reporting requirements.

Under the Open Payments program, drug and medical device manufacturers are required to report their financial interactions with licensed physicians – including consulting fees, travel reimbursements, research grants and other gifts.

The joint letter urges CMS to exempt journal reprints and medical textbooks from “Open Payments” reporting using a preexisting statutory exclusion for “educational materials that directly benefit patients.” The letter also urges the agency to play a more proactive role in the reporting process by working with stakeholders on a common set of definitions of what is reportable.

“We have long believed that the agency’s decision to include educational materials and CME programs as reportable transfers of value is contrary to both the statute and congressional intent,” states the letter. “[It] has harmed patient care by impeding ongoing efforts to improve the quality of care through timely medical education.”

The organizations that signed on to the letter agree that CMS’ decision to require reporting of medical textbooks and journal reprints makes it more difficult for busy physicians to stay abreast of the latest advances in medical care, therefore and ultimately compromising patient care. They also state the reporting guidance pertaining to CME continues to be misinterpreted with many manufacturers overreporting.

As previously reported by CMA, less than 6 percent of physicians who received payments actually looked at their records.

Physicians who are not already registered should be aware that there is a two-step process to register for the Open Payments program. The first step requires physicians to register at the CMS Enterprise Identity Management System portal, a step many physicians may have already completed as the gateway enables access to some other CMS programs. Step two is to register in CMS’ Open Payments system.

Physicians who have already registered, but who have not accessed their account in the past 60 days, will need to unlock their account by going to the CMS Enterprise Portal. It will prompt you to enter your user ID and correctly answer all challenge questions, then you will be prompted to enter a new password.

Users who registered last year, but who have been inactive for more than 180 days, will need to reactivate their account by contacting the Open Payments Help Desk at openpayments@cms.hhs.gov or (855) 326-8366.

CMA recoups $29 million on behalf of physician members

California physicians have a powerful ally when it comes to dealing with problematic payors—the California Medical Association (CMA) Center for Economic Services (CES). Staffed by practice management experts with a combined experience of more than 125 years in medical practice operations, the CES team has recovered $29 million from payors on behalf of its physician members over the past 10 years.

In 2018, CES had a record year, recovering nearly $11 million from payors on behalf of physician members, up from $3 million in 2017. This is money that would have likely gone unrecouped if not for CMA’s direct intervention.

CMA members can call on CMA’s practice management experts for FREE one-on-one help with contracting, billing and payment problems. Contact CMA’s reimbursement helpline today at (888) 401-5911 or economicservices@cmadocs.org. 

Learn more about how CMA’s practice management experts can help you at cmadocs.org/ces.