From: Name Withheld
I found this interesting article on the Stark law changes that occurred on Jan 1, 2022, and it also provides detailed explanation regarding designated health services (DHS) with respect to physician compensation in a group practice. After being in solo practice for nearly three decades, the only time I knew about the Stark law was regarding the exception of self-referral and in-office x-ray, and that was it. Boy, was I in for a rude awakening. So, this is a rather eye-opening article indeed and should be considered a warning to any new resident or fellow graduate or anyone who is planning on signing an employee contract in a hospital-based or group practice. Do your due diligence before signing the contract.
Outside of the volume of physician services that are a basis of compensation for physicians (usually a contracted percentage minus collection and non-claim overhead expenses), these ancillary services provided by a physician in a group practice better known as DHS are paid to the physician via...
Editor's note: Name Withheld's extended-length letter can be read here.
Query: New Vs. Established Patient After Practice Merger
I am merging my podiatry practice into a large Ortho practice; can I bill my prior patients as new vs established?
Response from thedoctorline.com: In the context of your practice’s merger and the new Tax Identification Number (TIN), it’s important to understand how Medicare defines “new” and “established” patients for billing purposes. According to the Centers for Medicare & Medicaid Services (CMS), a new patient is one who has not received any professional services—such as Evaluation and Management (E/M) services or other face-to-face services—from the physician or another physician of the same specialty within the same group practice in the past three years.
This definition hinges on the National Provider Identifier (NPI) rather than the TIN. Therefore, even though your practice is adopting a new TIN due to the merger, patients previously seen by you or another podiatrist in your group within the last three years are considered established patients. Billing them as new patients solely based on the new TIN would not align with Medicare’s guidelines.
However, if these patients are now consulting with an orthopedic specialist in your merged practice and have not seen an orthopedic specialist within the same group in the past three years, they may be classified as new patients for that specialty. This distinction is based on the specialty of the provider rendering the service. Additional coding and billing questions and responses can be found at thedoctorline.com.
Query: Rejected Claims for Medicare DME to Novitas Solutions
Has anyone had recent issues with rejections of claims for DME products (i.e., L4360 CAM walker)? We have been submitting these claims with laterality and -KX modifiers. Now, out of nowhere, they are rejected saying "invalid information as specified in status details." We have tried new modifier combos, just -RT or-LT, just- KX, added -NU... none work. We called them and they said modifiers are incorrect but would not tell us what to use since that info is locked up with the nuclear codes. If something has changed, they never informed us. Anyone else with the same issue or any suggestion appreciated.
Larry Goldstein, DPM, Warner Robins, GA
Response from thedoctorline.com: This issue was partly due to the confusion of the provider and incorrect information in the claim, both of which resulted in a front end rejection. The provider thought it was "their own" clearinghouse, but in fact it was CEDI=Common Electronic Data Interchange, which is the DME MAC clearinghouse which rejected the claim. Thus it was Medicare's own clearinghouse which was not at fault but actually where the front end rejection took place.
A front-end rejection indicates that Medicare cannot process a claim as is, due to a severe fault with the claim, resulting in the claim not being processable or appealable as submitted. Some examples, incorrect information in the Common Work File vs. what the claim contains. This could have included wrong DOB, name spelling vs. MBI, etc. Others include wrong "other insurance information". Reaching out to CGS ombudsmen, it turned out to be the latter. Dr. Goldstein was contacted and the claims were corrected and resubmitted and currently are processing. Additional coding and billing questions and responses can be found at thedoctorline.com
Paul Kesselman, DPM, Oceanside, NY
