When it’s OK to discount, how to bill for foreign-body removal

October 25, 2013

By Walt Whitley, O.D., Jason Miller, O.D., and Chuck Brownlow, O.D., AOAExcel™ medical & records consultants

This month’s column will answer some of the common questions about discounts and billing we receive from colleagues from across the country. If you have any particular billing and coding questions, email us at askthecodingexperts@excelod.com.

Question: I recently heard practices in surrounding areas were offering certain discounts on their exams. My question is whether or not prompt-pay discounts are legal?

Answer: The only acceptable discount to offer is a prompt-pay discount offered to all patients even if they have insurance. Most payers understand the acceptability of prompt-pay discounts while their contracts often require doctors to bill them using their usual fees, effectively prohibiting doctors from providing discounts to patients simply because they are private pay.

It is understood that providing discounts to patients without insurance essentially creates a new usual fee from which payers will then take their discounts. Prompt-pay discounts must be given in exchange for payment on the same day of service. The discount should not be more than 20 percent of the usual fee and may be either for services, materials, or both. Medicare’s policy is to pay the lesser of the doctor’s usual charge or the Medicare Fee Schedule amount. Most insurers believe “usual” equates to the charge you would bill to a private-pay patient.

Additionally, occasional discounts are all right for any reason, as long as they don’t create a pattern. For example, a doctor can provide a discount of up to 100 percent in special circumstances, such as for clergy or good friends or for the indigent. It is dangerous, however, to provide discounts for a significant percentage of one’s practice unless such discounts comply with the rules of prompt-pay discounts (alternatively termed cash discounts or day-of-service discounts). The significant percentage is believed to be close to 35 percent of the total practice.

Question: Can I bill an office visit 99213 with superficial conjunctival foreign body removal (65205)? If 99213 can be billed, should I add a modifier? If so, which modifier is appropriate?

Answer: If the reason for the visit was something other than the finding of or subjective complaints associated with that foreign body, then yes. The surgical code, 65205, includes the finding of the foreign body and is reimbursed at a higher rate because of that.

If the patient visits for a different reason, then billing a 99xxx code or 92xxx code with a different diagnosis and attaching modifier 25 would be appropriate.

Modifier 25 = Significant, Separately Identifiable Evaluation and Management Service by the Same Physician on the Same Day of the Procedure or Other Service.

Practitioners may need to indicate that on the day a procedure or service identified by a CPT code was performed, the patient’s condition required a significant, separately identifiable evaluation & management (E/M) service above and beyond the other service provided or beyond the usual preoperative and postoperative care associated with the procedure performed.

A significant, separately identifiable E/M service is defined or substantiated by documentation that satisfies the relevant criteria for the respective E/M service to be reported (see Evaluation and Management Services Guidelines at http://go.cms.gov/16qBclB for instructions to determine the level of E/M service).

The E/M service may be prompted by the symptom or condition for which the procedure and/or service was provided. As such, different diagnoses are not required for reporting of the E/M services on the same date. This circumstance may be reported by adding modifier 25 to the appropriate level of E/M service. Note: This modifier is not used to report an E/M service that resulted in a decision to perform surgery.

Contact us with any other questions. In our upcoming October webinar, we will discuss “Updates on HIPAA and ICD-10.” For more information, visit www.ExcelOD.com/events. We hope to “see” you there!

The views expressed are those of the authors and do not necessarily reflect the views of the AOA.

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