Q&A From APA Help Line
The Office of Healthcare Systems and Financing's (OHSF's) Managed Care Help Line is a valuable resource for APA members. Each day, OHSF staff provide information and intervention to help callers solve problems they are encountering with regard to payment, Medicare, coding, documentation, and denials of access to care for patients, among others.
What follows are some of the questions that Help Line staff members have answered frequently over the years with uncomplicated answers. Many of the questions the Help Line receives are too complex, or too specific, to put into a Q&A format. If you're having a problem that isn't addressed below, please contact the Managed Care Help Line at (800) 343-4671 or [email protected].
Coding
Help Line staff requests that coding questions be sent via e-mail ([email protected]) or fax (703-907-1089) to avoid confusion.
Q.If, upon examining a patient, I find that neither psychotherapy nor medication is needed, does this negate the use of 90801, the code for a psychiatric diagnostic interview examination?
A. No, it doesn't, but if the evaluation was requested by another physician, it might go easier with insurers to use an outpatient consult code instead. If you do use a consultation code, the record must include the other physician's request and a copy of the report sent back to him or her.
Q.When a patient is seen at an assisted living facility (ALF), should an inpatient or out-patient CPT code be used?
A. Outpatient. For an ALF, use place of service (POS) code 13, which is for a residence. The inpatient POS code is 21, and the office code is 11.
Q.How do I choose between a psychotherapy code with E/M and code 90862?
A. Look to the primary service you provided. If you have seen the patient for medication management only and provided minimal or no psychotherapy, choose 90862. If you have primarily had a psychotherapy session during which you evaluated the patient's medication regimen, choose the appropriate psychotherapy code with E/M based on the length of the session.
Medicare
Q.Our office charges patients a missed-appointment fee if they fail to provide 24-hour notice that they will miss an appointment. Can we charge that same fee to our Medicare patients?
A. Yes, as long as the patients are informed of the policy at the start of treatment. Since Medicare does not cover missed appointments, you can charge Medicare beneficiaries the same fee you charge your non-Medicare patients.
Q.I see Medicare patients in the hospital and at the university clinic as part of my employment at the medical school, but I am starting a private practice and don't want to deal with Medicare there. Because I'm seeing Medicare patients in another place, must I also see them in my private practice?
A. No, you don't have to take Medicare patients in your private practice if you don't want to. However, if you do see a Medicare patient in your practice, even inadvertently, you must file claims with Medicare because you are officially a Medicare provider based on the Medicare services you provide at the other facility.
Q.The Medicare contractor for my state asked to see documentation after I submitted several claims. I sent the documentation, but the claims were denied because the documentation was deemed insufficient. The denial letter notified me of my right to appeal. Is there any point in pursuing an appeal in a case like this?
A. Yes, APA always advises members to appeal denials of care to Medicare patients. Even though you may fail at the early levels of appeal, if you pursue your appeal to the administrative law judge (ALJ) level, you have a very good chance of winning. Information on the Medicare appeals process can be found on the APA Web site at<www.psych.org/MainMenu/PsychiatricPractice/MedicareMedicaid/AppealingMedicareCarrierDecisions.aspx> or can be obtained by contacting the Managed Care Help Line.
Q.What is the difference between a participating (par) or nonparticipating (nonpar) provider with Medicare?
A. A participating provider “accepts assignment,” which means the patient has to pay only the copay, and the provider files the claim with Medicare and is reimbursed directly for the rest of the fee. A nonparticipating provider still has to file claims with Medicare but is paid the full amount by the patient, who is then reimbursed by Medicare.
Nonparticipating providers can charge up to what is called a limiting fee, which means they are permitted to receive about 9 percent more for their services than participating providers. However, when seeing a patient for whom Medicare is the secondary payer, nonparticipating providers are still bound by the limiting charge, while participating providers are permitted to charge a higher fee if the primary insurer happens to pay more than Medicare.
Q.How can I find out the Medicare fees for the procedures I provide?
A. Medicare Part B contractors (carriers or administrative contractors) must post the fees on their Web sites. If you cannot find the appropriate Web site, call the Managed Care Help Line.
Q.Several of my colleagues tell me they've opted out of Medicare. What is the advantage of doing so? I have never enrolled in Medicare and don't have any Medicare patients.
A. Opting out of Medicare allows you to have private contracts with Medicare beneficiaries and permits you to charge them your usual fees instead of being bound by the Medicare fee schedule. Even though you don't have any Medicare patients, some of your patients may age into Medicare at 65 or become beneficiaries because of disability. If you want to continue seeing these patients, you must either enroll in Medicare and begin filing claims for them or opt out of Medicare and have the patients sign private contracts. Otherwise, you must tell the patients you can no longer see them.
Q.I have never enrolled as a Medicare provider and would like to opt out of the program. When I contacted my Medicare carrier, I was told I had to enroll before I opted out. Is this true?
A. No. The Medicare carrier (or contractor) does need to be able to identify you, however, so you must provide your NPI, as well as your address, tax identification number, and medical license number. If you use the opt-out affidavit posted on APA's Web site, you will provide the carrier with all the necessary information. The affidavit can be accessed at the bottom of this Web page:<www.psych.org/MainMenu/PsychiatricPractice/MedicareMedicaid/OptingOutofMedicare.aspx>. If your affidavit is denied, contact the Managed Care Help Line.
Q.I don't have any Medicare patients and would like to opt out of Medicare, but I've applied for an academic position where I may have to see Medicare patients. Should I opt out of Medicare?
A. When you opt out of Medicare, you are making a two-year commitment not to provide any services under Medicare. If you think there's any chance you may see Medicare patients during the next two years, you shouldn't opt out.
General Practice
Q.I don't take any insurance in my practice. Is there any reason why I need to have an NPI?
A. Yes. Even though you don't take any insurance, your patients may want to get reimbursed from their insurers for your services or use their insurance to cover tests you order. They won't be able to use their insurance unless you have an NPI.
Q.How long do I have to keep patient records? I am closing my practice and am not sure what to do with them.
A. Each state has its own laws about how long medical records must be retained. Your APA district branch should be able to provide you with this information.
Q.I am thinking of becoming part of a managed care network but have been unable to obtain a copy of its fee schedule. What should I do?
A. Tell the company that you will not sign a contract until you are given the fee schedule—and stick to that position.
Q.I appealed a negative decision by a managed care company for treatment I provided to a patient insured by the company. I lost the appeal. Is there any point in continuing to appeal?
A. Yes. Most managed care companies have multiple levels of internal review, and if these all fail, 44 states require independent external review of appeals after you have exhausted all the internal levels. You have a good chance of winning at this level.
Q.A managed care company I contract with has failed to pay some claims filed more than six months ago. What is my recourse? Can I collect interest on the money that the company owes me?
A. Most states have prompt-payment laws on the books that cover situations like this. You can check with your state's insurance commissioner to find out how to proceed. To find out how to contact your insurance commissioner, go to<http://www.naic.org/state_web_map.htm>.
Q.A managed care company I contract with asked to look at specific patient records for a quality assurance check before I can be reimbursed. Should I comply?
A. Yes, you need to comply if providing patient records for this purpose is stipulated in your contract. Managed care companies' accrediting bodies require that they carry out this kind of activity. If you believe the request is contrary to your philosophy of patient confidentiality, however, express your concerns to the company and try to work out a compromise, such as providing redacted records. ▪
