SDCMS Medical Officer Manager Bulletin Board (2010.11)

ASK YOUR OFFICE MANAGER ADVOCATE

Question: Our physician has been having difficulty getting reimbursed from a certain health plan. I think they are having financial difficulties because they are giving me the runaround when I call to follow up. What can I do at this point?

Answer: You have a few options. First, continue to follow up with the health plan and track the communication and progress on a spreadsheet. For IPA solvency issues, submit the claims for payment to the underlying health plans and notify them that the claims remain unpaid by the IPA. Request that they pay the claims and deduct the capitation from the IPA.

Your other option is to have your physician request a meet-and-confer with the medical director of the IPA. Send the request by certified mail with return receipt and ask that the meet-and-confer be scheduled within two weeks. Let the IPA know you want to continue to provide quality care to their enrollees but are concerned they are not paying you within the timeframe specified by California law.

Another option is to file a formal complaint with the Department of Managed Health Care (DMHC). You can do this via webportal — click on “File a Provider Complaint.” CMA has developed a payor solvency checklist to assist you in navigating through these issues. For further information regarding payor solvency, consult CMA ON-CALL document #1051, “Physician Complaints About Managed Care,” and #0131, “Insolvency of Health Plan, IPA, or Other Entities That Contract With Health Plans (Pre-bankruptcy or Closure).”

CODING CORNER, BY MICHELLE PENA, CPC, CHMB

Question: How can I prevent denials for office visits when billing for the administration of therapeutic injections (CPT 96372)?

Answer: According to the Correct Coding Initiative (CCI), new patient and established patient office/outpatient visits are considered components of the admin code. If there is documentation to support a “significantly, separately identifiable evaluation and management service by the same physician on the same day of the other service,” a -25 modifier may be appended to the office visit CPT. It is important to review specific payer payment policies as not all payers apply their bundling edits according to the CCI.

Question: Why is Medicare denying the biopsy of a lesion (CPT 11100) with destruction of actinic keratoses (CPT 17000)? The documentation does support separate lesions, therefore we append -59 modifier to the destruction.

Answer: Commonly, the -59 modifier is appended to the CPT with the lower RVU or fee. This is not the correct placement of the modifier per coding edits. The modifier should be placed on the column II or component CPT. In this case, when reviewing the Correct Coding Initiative (CCI) edits, the 59 modifier should be placed on the 11100 due to its being considered the second code in the CCI pair.

References:

• OIG
• EncoderPro

OFFICE MANAGER “TO DO” LIST

• Check out version 3 of our SDCMS website. It has some new and improved features.
• Need an OSHA new hire checklist, click here.
• Email your Office Manager Bulletin Board questions to SGonzales@SDCMS.org.

SAVE THE DATES

• November 20: “Preparing to Practice” Workshop
• January 13: “Collection Procedures” Seminar / Webinar
• January 20: “Palmetto GBA/Medicare Provider Enrollment” Seminar / Webinar
• January 26–27: “Simple Approaches to Informed Consent and Informed Refusal” Seminar / Webinar
• February 3: “Treating Patients Right” Seminar / Webinar

MESSAGE FROM OUR 2009 OFFICE MANAGER OF THE YEAR BY ANNE BILLETER

It has been a great honor to be chosen as the 2009 “Outstanding Office Manager” by SDCMS. It was a joy to read the letter of nomination sent to SDCMS by the North County Internal Medicine (NCIM) physicians. I was certainly fortunate some 17+ years ago to be selected as their office manager. It has been a pleasure to work with this group of professionals, who are not only excellent clinicians, but take an active interest in all areas of their business. Every Friday at noon, you will find us, agendas in hand, participating in our weekly management meeting. During this hour, group, individual physician, and management problems or concerns are addressed.

As all office managers and practice administrators know, we are sometimes too busy moving about our days to acknowledge all those who contribute to a successful workplace. This honor, awarded to me by SDCMS, belongs to all employees of NCIM for their individual and group contributions to a top-notch organization. Their support, energy, and team effort creates an environment of positive support, not only for our patients but for the physicians and management of NCIM.

Here are a few of my ideas on how to build a successful team:

1. Hire employees who meet the skill set and personality for the position.
2. Create a relationship of trust with employees. Take the time to learn their strengths and weaknesses, and, whenever possible, incorporate their strengths into their job duties.
3. Administrative flexibility. We all have families, as well as “real lives” after 5 p.m. Some days real lives need to begin at 3 p.m. Acknowledging and accommodating employees’ “real lives and needs” will reap rewards.
4. Employees need permission to problem-solve. They may need a bit of direction, but in most cases it does not require management involvement. If a problem persists, ask them to identify the problem in writing along with a list of their suggested solutions.
5. Cross-train. At some point we all get bored with our day-to-day duties. Whenever possible, let the employee choose the desired position and allow them to expand their skills.
6. Managers should never become “friends” with the staff. It is imperative that you remain objective and neutral as a whole and not to an individual.
7. Work through generational quirks. If we are all working toward a common goal, we will find that there is always more than one right way to solve a problem.

I am very fortunate to be surrounded by employees who never fail to offer me assistance. After a recent week’s vacation, I arrived at the office to find my desk was neat and organized. Dene, my partner, dragon slayer, and gift from heaven, had, once again, created order out of chaos. There were three packed folders: “Before you get coffee,” “When you finish the first,” and the third folder labeled “Whenever.” I quickly opened my drawer to write her a thank-you note and discovered that my supportive, resourceful, dependable Lisa had cleaned and organized my “junk” drawer. Who knew that I had 50 Pilot pens in that tiny drawer?

I like this place. It’s a comfortable home away from home.

“Thank you, Anne, for being such an inspiration to all the office managers in San Diego County!” — Sonia Gonzales

ASK YOUR PHYSICIAN ADVOCATE

Question: If we have a patient whom we suspect may be getting controlled prescription medications from different physicians, or going to different pharmacies. Is there a centralized way that we can look into/report this possibility?

Answer: Yes. The state has a database known as the Controlled Substance Utilization Review and Evaluation System (CURES), which contains more than 100 million entries of controlled substance drugs that are dispensed in California. This real-time access Prescription Drug Monitoring Program (PDMP) system allows pre-registered users, including licensed healthcare prescribers, pharmacists, law enforcement, and regulatory boards, to access real-time patient controlled substance history information. The role of PDMP entrusts that well-informed prescribers and pharmacists can and will use their professional expertise to evaluate their patients’ care and assist those patients who may be abusing controlled substances.

To obtain access to the PDMP system, prescribers and pharmacists must first register with CURES by submitting an application form electronically. In addition, your registration must be followed up with a signed copy of your application and notarized copies of your validating documentation, which includes: Drug Enforcement Administration (DEA) registration, state medical license, and a government-issued identification. You can mail your application and notarized documents to Bureau of Narcotic Enforcement (BNE); Attention: PDMP Registration; PO Box 160447; Sacramento, CA 95816.

Another option would be to forgo the notary and present your documents in person, where sworn personnel will validate and collect your supporting documentation. San Diego’s Bureau of Narcotic Enforcement office is located at 9425 Chesapeake Drive; San Diego, CA 92123-1302, telephone (858) 268-5300, fax (858) 268-5353.

You can also fill out a manual Patient Activity Report (PAR) should you not wish to register online.

HIPAA and all confidentiality and disclosure provisions of California law cover the information contained in this database. All users must comply with HIPAA Privacy Rule requirements when using the Prescription Drug Monitoring Program System.

Question: I’m assuming that if I find multiple physicians who have written narcotics on one of my patients, there will not be a “confidentiality” problem with me notifying these other doctors without the patient’s consent. Is there actually an obligation for me to do that?

Answer: According to CMA ON-CALL document #0515, “Drug Prescribing: Unauthorized,” “Generally, unless a patient’s medical information is protected by the federal confidentiality laws governing drug and alcohol abuse treatment information or by state laws governing information pertinent to a state drug treatment program, it is lawful for a physician or pharmacist to convey information regarding a patient’s potential abuse of prescriptive substances to another healthcare professional or pharmacist.” This document also has a section titled, “No Legal Duty to Report,” in which is stated, “Moreover, although there is no statutory duty to share such information with other healthcare practitioners or pharmacists, unless prohibited by law, such information should be shared with other treating providers where such communication is required by the standard of care to protect the patient’s health. In addition, physicians should warn the patient about the hazards of drug abuse.” SDCMS-CMA members can obtain this CMA ON-CALL document by contacting SDCMS at (858) 565-8888.