Posts Tagged ‘PC’

If your practice can’t seem to successfully bill for the professional component lately, there could be a logical explanation. It could be something as simple as an incorrect modifier.

According to First Coast Service Options Inc. (FCSO), an excessive number of claims from providers are being denied because they request payment for the professional component using the wrong modifier with the CPT^® or HCPCS Level II code.

Prevent Delays and/or Denial

When billing for the professional component of a procedure, hospital outpatient departments, ambulatory surgical centers (ASCs), and other practitioners should properly identify the service by adding modifier 26 Professional component to the appropriate CPT^® or HCPCS Level II code — not the new modifier effective July 1,  PC Wrong surgery on patient.

Medicare automatically denies all lines related to an erroneous surgery with dates of service on or after Jan. 15, including claims for related hospitalizations.

Claims Appeal

FCSO advises providers appeal claims billed in error with modifier PC and subsequently denied for wrong surgery. Correcting and resubmitting these claims won’t work. Only an appeal will remove the edit logic that was installed for the beneficiary and date of service of the wrong surgery based on the initial claim.

The rapid increase of ultrasound services nationwide has Medicare watchdogs on the alert. Health care practitioners who submit Part B claims for technical and professional ultrasound services can expect added scrutiny. A recent Office of Inspector General (OIG) report provides insight as to what Medicare Administrative Contractors (MACs) will soon be on the lookout for when reviewing imaging service claims.

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It seems the new date of service (DOS) for the technical component (TC) of pathology, mandated by the 2007 Medicare Physician Fee Schedule (MPFS) final rule and implemented May 23, 2008, has caused some confusion. Does the DOS requirement apply to pathology tests when the TC and professional component (PC) are performed by the same lab and billed globally? Enquiring minds want to know!

To clarify, the Centers for Medicare & Medicaid Services (CMS) recently updated Pub. 100-04, Medicare Claims Processing Manual, chapters 1 and 16.

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Contractors will soon process Medicare claims for diagnostic tests subject to the anti-markup payment limitation based on new rules outlined in the 2009 Physician Fee Schedule (PFS).

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