Addressing some billing questions recently received

Addressing some billing questions recently received

Two items that may effectively address the rejections of BCBS claims submitted and additional referral issues:

1-   When reporting a service, either the adjustment or an ancillary procedure, regardless of the number of Dx codes you may have first submitted when the patient presented for their exam or re-evaluation, only the codes that relate to the performed procedure are the ones that should be appended to the reported procedure. Hence the Dx codes are “pointers” that tell the reviewer what and WHERE you performed the procedure. Hence if the patient first presented with three areas to be adjusted using all the codes you submit, yet you perform an ancillary procedure to one area, then Dx codes that relate to that area are the only ones to submit for that procedure. If in the future you reduce the number of areas you adjust, the Dx codes that relate to the specific area you adjust are the only ones to submit appended to the adjustment.

2-   Modifiers are often required for exams done the same day as the adjustment, hence appending a -25 modifier to the E/M code submitted. The higher-level evaluation and re-evaluation codes one reports, may also eliminate separate reimbursable coverage for the adjustment, and/or the ancillary procedure. Report them, just know why you may experience financial rejection. The extra-spinal ancillary manual procedures now require the new -XS, or another -Xx modifier, appended to the extra-spinal ancillary manual procedure, such as 97140. The -59 modifier is now not specific enough to point to the extraspinal area in question.

3-    If the provider still experiences rejections and you feel that it continues to be unjust and for which you can see no valid reason, you may find relief in this approach:

a. Ask your patient to call the consumer number on the back of their ID card and request that the carrier contact, by phone, the provider directly to discuss the rejects and update the Dx codes, or whatever else, to make the claim reimbursable. The patient contact will be taken more seriously, and the carrier is more apt to act on such a request. After all, the consumer pays the premiums, and we all expect that covered claims would in fact be covered! It may become an educational moment for both parties.

4-   Some hospitals have taken to rejecting chiropractic referrals, Cooley Dickenson being one with whom we have attempted dialogue. The most common referral is for x-ray, or other more advanced imaging, and secondarily, for laboratory work also. The only valid and understandable rejectable reason is that the patient is Medicare insured, and the federal guidelines require referral for many procedures upon MD referral only. It may be possible to do a workaround, whereby the DC makes a referral, with a records request, to an urgent care facility, one with the MD on staff, and an x-ray on-premises. Many find that it is more convenient because the wait time is often much less, the MD is the Medicare required referring physician upon performing their own evaluation, and the DC will get an x-ray report, and often the x-ray disc directly, for personal review and chiropractic evaluation. It is an additional pathway for appreciation of the work done by chiropractors and a potential future collaborative referral source.

We hope these suggestions are clear and helpful. Please contact MCS central, leaving your name, return phone number, and email address, so that we may contact you again directly. Share your concerns because they are not unique to your office alone. … Al Kalter