Modifier 32 Mandated services applies when a third party, such as an insurer or government agency, specifically requests/requires a service on a patient’s behalf. For instance:
• An insurer requests an independent evaluation of a patient filing a workers’ compensation claim
• A school requires that all students receive a physical exam prior to participating in a sports program
• A child in state custody is sent to your office for an examination after being placed in temporary custody or foster care.
• An insurer seeks a “second opinion” on a patient’s condition, prior to authorizing further testing and/or treatment.
For example, a cardiologist determines that a patient needs a mitral valve replacement for a mitral valve prolapse; however, the patient has had this condition for several years. The insurance company covers mitral valve repair, but requires a second surgical consultation prior to surgery.
The cardiologist providing the second opinion should report his service with a modifier 32 to show that the insurance company mandated the service, and therefore should be covered. Failure to report modifier 32 may result in a denial (for instance, due to “duplication of services” because another physician may have already provided the service).
Second opinions or confirmatory consultations requested by the patient, or the patient’s family, do not qualify for modifier 32. Neither is modifier 32 used for a consultation with another physician, or when another physician evaluates a patient for medical clearance prior to a procedure.
Finally, note that Medicare payers generally do not accept modifier 32 claims, and will not pay for a service requested by another provider.
April 16th, 2013
With the recent release of an updated Advanced Beneficiary Notice of Noncoverage (ABN) form, and especially given the fact that previous versions of the form will no longer be accepted, Becker’s ASC Review published a review of basic tips for ABN use, as compiled by AAPC. Tips and best practices include reproducing the ABN directly from the Centers for Medicare & Medicaid Services website, not using an ABN to bill a patient for additional fees beyond what Medicare reimburses, and knowing that these forms are never required in an emergency or urgent care situation.
Read the full article.
November 21st, 2012
Best practices dictate that providers should appeal any claims believed to be wrongfully denied, but if your practice has received a string of claims denials for certain Medicare Part B services rendered to skilled nursing facility (SNF) patients in the past 18 months, you may just need to sit back and wait. The Centers for Medicare & Medicaid Services (CMS) and your Medicare administrative contractor (MAC) are already at work identifying all claims erroneously denied because of a claims processing issue in the 2012 annual update of the HCPCS codes for SNF consolidated billing. (more…)
September 26th, 2012
In a final decision memo, the Centers for Medicare & Medicare Services (CMS) says there is insufficient evidence that autologous platelet-rich plasma (PRP) improves health outcomes in individuals with chronic diabetic, pressure, and/or venous wounds.
PRP used to treat chronic non-healing diabetic, pressure, and/or venous wounds may be covered under Medicare only when the beneficiary is enrolled in a clinical research study that addresses the following questions using validated and reliable methods of evaluation:
“Prospectively, do Medicare beneficiaries who have chronic non-healing diabetic, pressure, and/or venous wounds who receive well-defined optimal usual care along with PRP therapy, experience clinically significant health outcomes compared to patients who receive well-defined optimal usual care for chronic non-healing diabetic, pressure, and/or venous wounds as indicated by addressing at least one of the following:
a. complete wound healing;
b. ability to return to previous function and resumption of normal activities; or
c. reduction of wound size or healing trajectory, which results in the patient’s ability to return to previous function and resumption of normal activities?”
Clinical study applications for coverage must be received by CMS no later than Aug. 2, 2014; and the study of PRP must adhere to standards of scientific integrity and relevance to the Medicare population, as outlined in the decision memo.
CMS formally opened a third reconsideration of the national coverage analysis (NCA) on autologous blood-derived products for chronic non-healing wounds Nov. 9, 2011 and posted this final determination Aug. 2, 2012.
August 9th, 2012
The Centers for Medicare & Medicaid Services (CMS) has opened a National Coverage Analysis (NCA) for the Ocular Photodynamic Therapy (OPT) National Coverage Determination (NCD 80.3.1) after receiving a formal written request from the American Academy of Ophthalmology on May 25.
OPT is a treatment for age-related macular degeneration (AMD), a common eye disease among the elderly. AMD is the leading cause of blindness in adults over the age of 50. OPT involves the infusion of an intravenous (IV) photosensitizing drug called verteporfin followed by exposure to a laser. The laser activates verteporfin, which selectively targets and treats the pathologic ocular tissue. Verteporfin therapy is neither a cure nor a preventative for AMD; it is meant to slow progression of the disease.
The American Academy of Ophthalmology notes that the current coverage decision for OPT is from 2004, prior to the emergence of targeted anti-VEGF intravitreal treatments, and that these newer therapies have largely supplanted OPT as initial management of AMD, and that OPT is largely relegated to patients in whom the newer therapies have failed. The American Academy of Ophthalmology believe that the current NCD requirement for follow-up fluorescein angiography with OPT is not supportable for these end-stage patients.
CMS is interested in receiving evidence speaking to the need for fluorescein angiography with OPT in patients for whom targeted anti-VEGF intravitreal therapy has failed. The initial 30-day public comment period begins July 24, 2012.
July 26th, 2012