04/09/2018
Billing 99304 or 99307 and/or 1172X OR 1105X for Long Term Care Patients with Workers Compensation as Primary-Non Participating Provider
I have two questions: 1) I am seeing patients admitted for Long Term Care at Nursing Homes who show the Primary Insurance as Workers Compensation. I am not a participant in Worker's Comp. The rendered Podiatric Services are non-Comp related services for foot care ie. 99304 or 99307 E&M and/or 1172X and/or 1105X (modifiers as appropriate). For Medicare Eligible patients who gets billed when my software Eligibility Program shows Workers Comp as Primary? What is the correct way to bill for Podiatric Services of these patients? 2) When I am not a participating Provider in a specific Insurance Plan and have Physicians Orders to see patients for Long Term Nursing Home Podiatric Care can I request a Single Contract Agreement with that Insurance to continue to see the patient? Does this apply to patients who I've seen who switch to a Non-Par Plan? Can this be done when I see a New Patient in a Plan I do not participate with? Thank you
When services are rendered in a nursing home, even for a new patient, a podiatrist may not bill for a new patient nursing home visit (CPT 99304). New patient nursing home E&M codes may only be billed by the physician (usually a primary care physician) who is admitting the patient to the facility- only established patient E&M codes may be billed by a podiatrist.
If the patient is covered by worker's compensation, they would not be the payer for routine foot care services because in most cases, podiatry care would not be related to the injury or diagnosis that would be covered by the workers compensation claim. Medicare should be billed as the primary insurance- in the event that a claim is denied by Medicare because of COB (WC being the coverage primary to Medicare), proof would need to be obtained from the adjustor of the patient's claim stating that podiatry services are not covered under WC and that they should be the responsibility of Medicare to pay. The proof will have to be sent as part of a redetermination after a claim is denied by Medicare with the additional information faxed to NGS. If the patient is seen on a regular basis, every claim may need to be appealed with a redetermination with proof from the WC carrier that podiatry services are not related to the injury and that the services are not covered by WC, depending on how long the claim is open, and if WC is eventually removed as the primary insurance from Medicare's COB file.
If a provider is non-par (for commercial or Medicare payers), there are two ways that a patient can be seen without participating in the patient's insurance:
- Call the insurance and request an authorization for every CPT code expected to be billed, so OON services are precertified- if this is not possible,
- Speak with the billing/UM department of the facility and determine a self-pay arrangement for services to be provided- this may need to be negotiated for every encounter if a patient is seen recurrently since the podiatrist does not participate with the insurance