Thanks to the vigilance of the Texas Medical Association’s payment specialists, Medicare administrative contractor Novitas Solutions updated its system to ensure all claims billed with place of service (POS) code 10 will be paid correctly.
TMA coding experts identified that POS 10 claims – used to indicate when patients receive telehealth services in their home, and not at a facility – were incorrectly processed at the facility rate, leading to lower payment.
After TMA specialists brought the issue to Novitas’ attention, the contractor announced it was investigating, and then announced its mass adjustment for payments to be paid at the higher non-facility rate regardless of specialty.
Shannon Vogel, TMA’s associate vice president of health information technology, acknowledged the win as “great advocacy.”
Here are other claims updates TMA’s payment specialists are tracking that physicians should be aware of:
Medicare Advantage
Physicians should also take note of their contracts as individual Medicare Advantage 2024 plans have expanded into 30 new Texas counties. Those with an all-product clause in their contract will now be listed as participating clinicians without submitting a request for participation, meaning physicians could be held liable for balance billing dual-eligible patients.
Most dual-eligible patients are cost-share protected, which means physicians must accept both the Medicare and Medicaid payments as payment in full, per Aetna. To avoid issues, physicians are encouraged to refer to the Centers for Medicare & Medicaid Services (CMS) guidance on dual-eligible categories to avoid balance billing patients that have Medicare and Medicaid.
Aetna
Aetna will publish new claims edits March 1, including a co-surgeon services coding update that aims to ensure timely payment.
Aetna will process a co-surgeon claim when two procedures are conducted on the same date of service, on the same patient, when the same procedure code is used, and when co-surgeon services are reported with modifier 62.
Modifier 62 is used to ensure that two surgeons of different specialties who work together as primary surgeons performing unique portions of a surgical procedure are paid for their individual contributions. Both surgeons must bill the same procedure code and date of service, and both must append modifier 62.
Additionally, starting April 1, Aetna Medicare Advantage will no longer pay for additional unit values for physical status modifiers. This aligns with mandates by CMS, which does not recognize these modifiers for additional payment beyond the usual fee for anesthesia services.
For more information on billing and coding, visit TMA’s comprehensive Billing, Coding, and Reimbursement page.
Alisa Pierce
Reporter, Division of Communications and Marketing
(512) 370-1469