Billing and Reimbursement for OMM SAUNORA PROM, DO VOMA APRIL 5,2014 Objectives Review billing codes Review modifiers Go over reimbursement rate Typical Billing Office visit + Procedure 99201-99205- New office visit 99241-99245- New consult office visit 99211-99215- F/U office visit Then Dx: 1. Medical dx: LBP 2. S/D of… Procedure modifier .25- that is a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service, suggests that the diagnosis must be different. .51- (multiple procedures) is used to inform payers that two or more procedures are being reported on the same day. A claim form that has modifier 51 appended to a CPT code(s) tells the payer to apply the multiple procedure payment formula to the CPT code(s) linked to the modifier 51, assuming the payer accepts this modifier. .50- Bilateral procedure .59-the distinct procedural service modifier, is reported with a CPT code combination when a coding rule has to be met, when another, more specific modifier (multiple-51 or bilateral-50) will not explain the situation to the payer, or when the code combination is correct, but the payer has a reimbursement edit in place. 99213 Insurance BCBS Cigna HK Medicare Humana MC Optima Self Tricare United H Average 99213 $91 $77 $97 $60 $76 $70 $82 $57 $93 $78 99214 Insurance BCBS Cigna HK Medicare Humana MC Optima Tricare United H Average 99214 $152 $132 $137 $97 $110 $124 $89 $140 $123 99243 Insurance BCBS Cigna HK HK+ Optima Tricare United H Average 99243 $191 $175 $167 $94 $171 $92 $190 $154 OMM : 98925-27 98925: $26-$42 Medicare: $27.50 98926: $33-$66 Medicare: $43.00 98927: $37-$92 Medicare: $56.00 98928: Medicare: $73 98929: Medicare: $ 87 National Average 98926 OMM: RVU’s OMT Code 2011 Work Value 2012 Work Value 98925 0.45 0.46 98926 0.65 0.71 98927 0.87 0.96 98928 1.03 1.21 98929 1.19 1.46 ICD-9 to ICD-10 Region ICD-9 ICD-10 Head 739.0 M99.0 Cervical 739.1 M99.1 Thoracic 739.2 M99.2 Lumbar 739.3 M99.3 Sacral 739.4 M99.4 Pelvic 739.5 M99.5 Lower Ext 739.6 M99.6 Upper Ext 739.7 M99.7 Ribs 739.8 M99.8 Abd. /Other 739.9 M99.9 Keep Track Of Time Time can be used to code when it is spent in educating the patient More than 50% of face to face office visit is spent on counseling or coordinating care Issues for Us Non-payment by HK+ Capitated payment by Anthem Clarification of modifiers for different insurers (.51, .59) THANKS! References/ Resources AOA- Physician practice management Jorgensen, D; OMT Coding Strategies to Boost Your Bottom Line CMS.gov
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