Showing posts with label BCBS. Show all posts
Showing posts with label BCBS. Show all posts

Friday, June 15, 2018

How to do the correction in Medical record after claim submission

Corrections in the Medical Record


If the original entry in the medical record is incomplete, contracting providers shall follow the guidelines below for making a correction, addendum, or amendment. Signature requirements as defined above apply to all corrections in the medical record.

a. Errors in paper-based records:

To add an addendum or amendment to paper-based records, draw a single line in ink through the incorrect entry, print the word "error" at the top of the entry, the reason for the change, the correct information, and authenticate the error by signing (including credentials) the notation with the date and time. Entries should not be antedated (assigned a date earlier than the current date). Errors must never be blocked out or erased.

b. Electronic medical records/Electronic health records:

i. Addendum

An addendum is new documentation used to add information to an original entry that has already been signed. Addenda should be timely with date and time of the addendum. Write “addendum” and state the reason for the addendum referring back to the original entry.

Complete the addendum as soon after the original note as possible. Identify any sources of information used to support the addendum. Entries should not be antedated (assigned a date earlier than the current date).

ii. Amendment

An amendment is documentation meant to clarify or provide additional information within the medical record in conjunction with a previous entry. An amendment is made after the original documentation has been completed and signed by the provider. All amendments should be timely with the date and time of the amended documentation. Write “amendment” and document the clarifying information referring back to the original entry.

Complete the amendment as soon after the original note as possible. Entries should not be antedated (assigned a date earlier than the current date).

5. Use of Medical Scribes

Scribes are not permitted to make independent decisions or translations while capturing or entering information into the health record or EHR beyond what is directed by the provider. BCBSKS expects the signing and dating of all entries made by a scribe to be identifiable and distinguishable from that of a physician or licensed independent practitioner. All entries made by a scribe are ultimately the practitioner’s responsibility; therefore, review of the documentation and verification of its accuracy, including authentication by the practitioner, is required.

BCBSKS requests for medical records

1. BCBSKS staff members conduct medical review of claims and seek the advice of qualified and, typically, practicing professionals when necessary. Contracting providers agree to accept the decisions made as a result of those reviews and to follow the appeals procedures established by this Policy Memo.

2. The entire review process itself includes the development of guidelines that relate to specific provisions of members' contracts; the processing of claims based on guidelines and medical records when indicated; the retrospective review of claim determinations; and the appeal process. BCBSKS seeks the advice of clinical professionals at appropriate points throughout the entire review process.

3. Contracting providers must submit all pertinent and complete medical records to BCBSKS within the time frame specified by BCBSKS when records are needed for the initial review of a claim or when records are requested for an audit. In most instances, BCBSKS will allow 30 calendar days for the production of the requested records. In certain unusual circumstances as determined solely by BCBSKS, BCBSKS will require providers to submit medical records without advance notice. In such cases, a BCBSKS representative will visit the provider's office during business hours and secure the requested records immediately. The provider agrees to provide the requested records immediately. Members' contracts permit BCBSKS to obtain medical records without a signed patient release.


4. The ordering/referring provider shall also provide medical records to the performing provider when requested for the purpose of medical necessity review. Additional documentation that is not a part of the medical record and that was not provided at the time of the initial request will not be accepted. Only records created contemporaneous with treatment will be considered pertinent. Services denied for failure to submit documentation are not eligible for provider appeal, and are a provider write-off.

5. If BCBSKS determines that the patient services provided by the contracting provider are not medically necessary, the claim is denied and is a write-off to the provider. If the services are requested by the patient after being advised by the provider of the lack of medical necessity and the daily record or patient chart has been documented to that effect and a written waiver is obtained by the provider before the service being rendered, charges for the services will be the patient's responsibility.



Saturday, March 16, 2013

BCBS of Texas - Accepted modifier

MODIFIERS – Professional Claims

BlueCross and BlueShield of Texas/HMO Blue Texas accept all valid CPT and HCPCS modifiers into the claims processing systems.

The following modifiers have logic associated with them that might impact the claim.

Modifier 22: Denotes an unusual procedural service. Should only be submitted on surgical procedure codes along with supporting documentation to justify the unusual service

Modifier 25: Denotes a significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service. Should only be submitted on an evaluation and management code, and medical records should reflect the significant, separately identifiable service.

Modifier 50: Denotes a bilateral procedure. Should be submitted only for those surgical procedures that can be performed bilaterally. See Multiple Surgery document or Surgery Introduction, SUR701.000 in the Medical Policy Manual for more information on bilateral procedures.

Modifier 62: Denotes two surgeons working together as primary surgeons. Both surgeons should submit this modifier on only those services where they are acting as primary surgeons. See Co-Surgery, SUR701.002 in the Medical Policy Manual for more information. NOTE: Physicians acting as co-surgeons cannot bill as assistants.

Modifier 66: Denotes surgical team. See modifier 62 above.

Repeat Procedures

Modifier 76: Denotes a repeat procedure by the same physician. Should be submitted only when a procedure is repeated on the same date of service by the same physician

Modifier 77: Denotes a repeat procedure by another physician. Should be submitted only when a procedure is repeated on the same date of service by another physician

NOTE for Modifiers 76 and 77: The procedure must be the same procedure. It is submitted on the claim form once and then listed again with the appropriate modifier.

Assistant Surgeon Modifiers

Modifier 80, 81, 82: Denote assistant surgeons. Should be submitted on those surgical procedures where an assistant surgeon is warranted. NOTE: Physicians acting as assistants cannot bill as co-surgeons.

Supervision of Physician Assistant, Advanced Nurse Practitioner or Certified Registered Nurse First Assistant

The following modifiers should be used by the supervising physician when he/she is billing for services rendered by a Physician Assistant, (PA), Advanced Nurse Practitioner (APN) or Certified Registered Nurse First Assistant (CRNFA):

AS Modifier: A physician should use this modifier when billing on behalf of a PA, ANP or CRNFA for services provided when the aforementioned providers are acting as an assistant during surgery. (Modifier AS to be used ONLY if they assist at surgery)

SA Modifier: A supervising physician should use this modifier when billing on behalf of a PA, ANP, of CRNFA for non-surgical services. (Modifier SA is used when the PA, ANP, or CRNFA is assisting with any other procedure that DOES NOT include surgery.)

-80 Modifier: PA’s, ANP’s, and CRNFA’s who are billing with their own provider number will not need to bill a modifier, unless they are billing as an Assistant Surgeon, then they must use the –80 modifier.

Technical and Professional Components

Modifiers 26 and TC: Modifier 26 denotes professional services for lab and radiological services. Modifier TC denotes technical component for lab and radiological services.

These modifiers should be utilized on the appropriate lab and radiological procedures only, and are inherent in provider fee schedules.

NOTE: When a provider performs both the technical and professional service for a lab or radiological procedure, he/she should submit the total service, not each service
individually

Wednesday, July 28, 2010

Modifier 22, 25, 47 - When to use

When a Modifier may not be covered - BCBS of  North Carolina

• Modifier -22 will not affect claims processing adjudication. In general, BCBSNC does not allow a
severity adjustment to fee allowances. Payment for new technologies is based on the outcome of the treatment rather than the "technology" involved in the procedure.

The modifier -25 will not be recognized with a minimal office visit for an established patient (99211) performed on the same date as a preventative medicine visit (99391 - 99397).

• Modifier -47 is used to report anesthesia by the attending or assistant surgeon. No additional benefits are allowed above the total allowed for the surgical procedure if the anesthesia services are not administered by, or under the supervision of, a doctor other than the attending surgeon or assistant surgeon.


Modifier 47 Anesthesia by Surgeon

Instructions

    Surgical allowable based on 50 percent of Medicare Physician Fee Schedule (MPFS)

Correct Use

    Regional/general anesthesia provided by surgeon/attending surgeon only
    Append 47 modifier to basic surgical service/procedure only

Incorrect Use

    Surgeon performs both surgery/anesthesia, separate payment not allowed
    Anesthesiologist not covered with 47 modifier
    Not appropriate with anesthesia codes or local anesthesia
    Not appropriate with moderate sedation (99143 – 99145)
    Not appropriate for monitoring general anesthesia provided by
        Certified Registered Nurse Anesthetist (CRNA), intern, anesthesiologist or resident

• Modifier -50 designates the performance of a bilateral procedure. Clinical consultant review may determine these services will not be allowed.

• Modifier -51 will not be accepted with evaluation and management services. If used, the claim for services will not be allowed. Response will be; “Invalid Modifier/Procedure Combination.”

• Modifiers -80, -81, and -82 for assistant surgeon services will not be allowed if they do not meet BCBSNC guidelines for appropriateness, Blue Cross and Blue Shield of North Carolina uses Claim Check as its primary source for determining those procedures available for assistant surgeon benefits. Claims will be denied if the assistant surgeon is not board-certified or otherwise highly qualified as a skilled surgeon. Claims with procedures determined not to require an assistant surgeon will be denied as; “Does Not Require An Assistant Surgeon.”

• Modifier GQ - Via asynchronous telecommunications system will not be allowed specifically with code 99201 - 99215(Office or Other Outpatient Services) and 99241 - 99245(Office or Other Outpatient Consultations).

• Modifier GT - will not be recognized with a minimal office visit for an established patient (99211).

• Modifier PA - Surgical or other invasive procedure on wrong body part. Refer to Corporate Medical Policy titled “Nonpayment for Serious Adverse Events”

• Modifier PB - Surgical or other invasive procedure on wrong patient. Refer to Corporate Medical Policy titled “Nonpayment for Serious Adverse Events”

• Modifier PC - Wrong surgery or other invasive procedure on patient. Refer to Corporate Medical Policy titled “Nonpayment for Serious Adverse Events”

BCBS covered modifier - when to use

When a Modifier may be covered - BCBS of  North Carolina

• Modifiers -62 and -66 designate services performed by two surgeons or a surgical team, and will be reviewed on an individual consideration basis.

• Modifiers -80, -81, and -82 designate assistant surgeon services. Blue Cross and Blue Shield of North Carolina uses ClaimCheck® as its primary source for determining those procedures available for assistant surgeon benefits. The assistant surgeon classifications assume that the assistant surgeon is boardcertified or otherwise highly qualified as a skilled surgeon. Automatic edits are performed on assistant surgeon claims to determine if any procedures have been inappropriately billed by a surgical assistant. If guidelines are not met, the claim will suspend.

• Modifier -AS designates that services were provided by a physician assistant, nurse practitioner or nurse midwife for an assistant at surgery. Blue Cross and Blue Shield of North Carolina uses Claim Check as its primary source for determining those procedures available for assistant surgeon billing by physician assistants, nurse practitioner or nurse midwife. Automatic edits are performed to determine if any procedures have been inappropriately billed by the physician assistant, nurse practitioner or nurse midwife.

• HCPCS site-specific modifiers E1-E4 (eyelids), FA-F9 (fingers), TA-T9 (toes), -RT (right), -LT (left), and -LC, -LD, and -RC (coronary vessels), are helpful in determining claims payment when multiple surgical procedures are performed on different anatomical sites during the same operative session.

• Modifier GT - Via interactive audio and video telecommunication systems will be allowed with code 99201 - 99205, 99212 - 99215(Office or Other Outpatient Services) and 99241 - 99245 (Office or Other Outpatient Consultations).

• Modifier - MS a six month maintenance and servicing fee for reasonable and necessary parts and labor which are not covered under any manufacturer or supplier warranty.

• Modifier - RP Replacement and repair may be used to indicate replacement of DME, orthotic and prosthetic devices which have been used for sometime.

• Modifier -TC designates technical component services were provided and will be allowed at a reduced rate in comparison to the allowance for the full service.

Tuesday, July 27, 2010

BCBS of North Carolina covered modifier

When a Modifier may be covered - BCBS of  North Carolina

• Modifier - 24 can be submitted with evaluation and management services. It is used to report an unre lated evaluation and management service by the same physician during a postoperative period.

• Modifier - 25 can be submitted with evaluation and management services for office, ambulatory, or outpatient department services. It is used to report a significant, separately identifiable  evaluation and management service by the same physician on the same day of a service.

• Modifier -26 designates the professional component of a procedure. The acceptance of modifier -26 with a procedure is based on HCFA RBRVS. When processing modifier -26, the professional RVU is allowed.

• Modifier -50 designates the performance of a bilateral procedure. The acceptance of modifier -50 with a procedure is based on clinical consultant review.

• Modifier -51 designates the performance of multiple procedures, other than evaluation and management services, indicating an additional service or procedure has been performed.

• Modifier -54 designates Surgical care only, for use when one physician performs a surgical procedure and another provides preoperative and/or postoperative management.

• Modifier -55 designates Postoperative management only, for use when one physician performed the postoperative management and another physician performed the surgical procedure.

• Modifier -56 designates Preoperative management only, for use when one physician performed the preoperative care and evaluation and another physician performed the surgical procedure.

• Modifier 57 - is an evaluation and management service that results in the initial decision to perform surgery.

• Modifier -59 designates a distinct procedural service, other than evaluation and management services.

Most read cpt modifiers