Author Topic: Bundled services G0439 with G0437  (Read 3912 times)

djk

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Bundled services G0439 with G0437
« on: April 29, 2014, 12:25:14 PM »
I am billing for a annual well visit (G0439-  modifer 25,Dx V70.0) and  for smoking cessation (G0437 DX 305.1), Medicare is bundling these services

Michele

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Re: Bundled services G0439 with G0437
« Reply #1 on: May 01, 2014, 11:11:28 AM »
Not sure if you had a question.  Do you feel that the smoking cessation should be allowed separately?  I believe that their guidelines specify that the service is included/bundled with the well visit unless there is something to indicate that the service was separate.
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djk

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Re: Bundled services G0439 with G0437
« Reply #2 on: May 02, 2014, 06:57:25 AM »
I think that should not be bundled services

Michele

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Re: Bundled services G0439 with G0437
« Reply #3 on: May 02, 2014, 08:56:03 AM »
You are a person of few words.  LOL  You are still leaving me with some questions.  Are you the biller?  I'm asking because I'm wondering why you feel that they should be separate.  Don't get me wrong, I'm not saying it is wrong to think they should be separate, just trying to get your angle.  I bill for a doc who does smoking cessation as well.  What I'm getting at is this.....  we can think something should be allowed separate but if the particular insurance carrier rule is that it isn't then there isn't much that can be done.  As a biller we have to be careful that we don't try so hard to get something paid that we actually alter the billing to do it.  The billing must match what is in the chart.  So for example:

Pt comes in for a well visit.  Dr performs well visit and also does smoking cessation.  It gets billed out as G0439 and G0437.  Medicare states that G0437 is inclusive of G0439, they don't allow it separate.  Period.  Even if the chart clearly shows dr performed complete check up, and then spent additional 10+ minutes on smoking cessation, it is not payable separate.   The biller believes it should be allowed separate so they append different modifiers etc in an effort to get them paid.  Maybe the biller even tries to bill a 99211 or other code.  This is not good.

Now if the Medicare guidelines state that if the smoking cessation is done along with another service but it is separate and a modifier can be appended to indicate that, then they will allow it separately, then that is different.  But the biller shouldn't just append the modifier to ensure the payment, they must make sure that the modifier is appropriate and that the patient's chart indicates that. 

We just have to remember that we are billing out what is performed exactly as it is performed to report it to the insurance carrier.  We are not billing just to ensure payment.  I'm sure everybody is up in arms right now, but hear me out.  I see so many billers get lost in "how do I get this paid?"  That is not the right question.  The question should be "am I billing this correctly."  Sometimes things are just not covered and it's patient responsibility, or the provider agreed to not bill separately in their contract.  Us billers are not magicians, we are just experts at billing correctly.  (Sometimes we need to get assistance from others to perform our jobs and to learn.)  Our job is not solely to make sure the provider gets paid, but to make sure the provider is reimbursed for all that they are entitled to in a timely manner and to make sure that the claims are being billed properly.

Ok not sure how I got that far off.  I hope I was helpful.  :) 
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PMRNC

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Re: Bundled services G0439 with G0437
« Reply #4 on: May 02, 2014, 09:39:25 AM »
Quote
We just have to remember that we are billing out what is performed exactly as it is performed to report it to the insurance carrier.  We are not billing just to ensure payment.  I'm sure everybody is up in arms right now, but hear me out.  I see so many billers get lost in "how do I get this paid?"  That is not the right question.  The question should be "am I billing this correctly."  Sometimes things are just not covered and it's patient responsibility, or the provider agreed to not bill separately in their contract.  Us billers are not magicians, we are just experts at billing correctly.  (Sometimes we need to get assistance from others to perform our jobs and to learn.)  Our job is not solely to make sure the provider gets paid, but to make sure the provider is reimbursed for all that they are entitled to in a timely manner and to make sure that the claims are being billed properly.

WONDERFULLY SAID!!!!!!!! 
Linda Walker
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djk

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Re: Bundled services G0439 with G0437
« Reply #5 on: May 02, 2014, 10:08:31 AM »
I just didnt want to confuse the situation with a lot of words//LOL  I am a biller and just want to get the monies the provider is due and bill correctly to get to that end..I guess the question is should i append a modifier to the G0439.

PMRNC

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Re: Bundled services G0439 with G0437
« Reply #6 on: May 02, 2014, 01:34:33 PM »
I had gotten the impression from your first post that you already tried the modifier 25?
Quote
I am billing for a annual well visit (G0439-  modifer 25,Dx V70.0) and  for smoking cessation (G0437 DX 305.1), Medicare is bundling these services

The way I understand the smoking cessation G codes is that they are ADD on codes to E/M.. I'm not sure Medicare will pay for it separately within a well visit so I'm not sure modifier 25 would work, if the documentation supports it I suppose you could try but I don't think you can append the modifier 25 to either G code?

http://thehappyhospitalist.blogspot.com/2009/10/cpt-99406-and-99407-and-now-g0436-and.html
Linda Walker
Practice Managers Resource & Networking Community
One Stop Resources, Education and Networking for Medical Billers
www.billerswebsite.com

Michele

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Re: Bundled services G0439 with G0437
« Reply #7 on: May 05, 2014, 11:23:04 AM »
I just didnt want to confuse the situation with a lot of words//LOL  I am a biller and just want to get the monies the provider is due and bill correctly to get to that end..I guess the question is should i append a modifier to the G0439.

I hope I didn't imply that you were trying to do anything wrong.  Just that I see so many billers confuse their position.  I do believe that Linda is right.  They may not cover it with a well visit but if it is documented I would certainly try the 25 modifier.

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barcafan1990

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Re: Bundled services G0439 with G0437
« Reply #8 on: November 04, 2015, 01:57:44 PM »
I'm having this issue now and I'm a bit confused.

We billed a G0439 along with a 99406 (no modifier) and Medicare paid. This was back on 9/17/15 (before the ICD 10 snafu).

On 10/19 (after ICD 10 deadline) we billed Medicare the same G0439 and 99406 (no modifier) for a different pt. This time Medicare denied the service as being a "routine service done in conjunction with a routine exam."

After carefully reviewing both claims, I first realized that neither 99406 even had the "required Dx pointer." On the 9/17 claim that would have been a 305.1 (ICD9) and on the 10/19 claim that would have been F17.200 (ICD10). These Dx were included on the claim but not as the specific Dx pointer for 99406.

That leads me to wonder if Medicare is more carefully reviewing these ICD-10 claims for the "required" Dx pointer before paying. Otherwise were we just lucky to have gotten paid that one claim. Or do I have a case as to why Medicare bundled one 99406 and not the other?
(And no, we had not billed the 8 maximum session yet)

Can anybody provide some insight? Where can I find Medicare's billing guidelines to find out if its supposed to be covered during an AWV. The latest Transmittal 2058 that I found does not specify during what types of visits can this be included with, AWV or E&M?
Josue M

Michele

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Re: Bundled services G0439 with G0437
« Reply #9 on: November 04, 2015, 04:07:19 PM »
This article talks about billing the 99406.  It does state that the E&M needs a 25 modifier.  It doesn't mention annual exams.  I do think it probably is required though however that doesn't explain why the paid the September one.  Personally I would call and speak to a representative to see if I could figure out why the one paid and the other didn't.

https://www.cms.gov/Outreach-and-Education/Medicare-Learning-Network-MLN/MLNMattersArticles/downloads/MM7133.pdf   
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barcafan1990

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Re: Bundled services G0439 with G0437
« Reply #10 on: November 04, 2015, 07:08:04 PM »
Thank you. I wanted to do some research and garner some courage that I'll need to take on their Automated "Prevent-me-from-reaching-a-live-person" System.
Josue M