What’s this new fee on my provider bill?

COVID-19 has turned the world on its axis and changes stemming from the pandemic can be felt across the board. One new norm you may have noticed the last time you headed to the doctor is a new line item on your receipt. That’s because many businesses including healthcare providers are now commonly adding a “COVID-19 surcharge.”

Why the surcharge?

Many practices are adding additional charges that can range from a flat fee (usually $15-$20/visit) to a percentage of the total bill. Providers are citing the surcharge as a way to counterbalance financial losses from being shut down and/or limiting business for months. More commonly, providers are using these funds to offset the operational costs of additional PPE equipment as well as additional cleaning and sanitization supplies and services.

Is the surcharge legal?

Much to the chagrin of some patients, the COVID-19 surcharge is completely legal. Patients appear to be split on their response to this additional fee: some are empathetic to the burden the new operational costs place on their providers. On the flipside, patients who may already be struggling financially in these uncertain times, are less understanding.

Regardless of the charges legality, healthcare providers should always implement best business practices and be as transparent as possible about this new line item. Patients should be told prior to their visit that there will be an additional fee. Practices may even want to go so far as to post a physical sign at their office as well as add a notification to their website.

Will the surcharge go away?

As we know, nothing in life is certain anymore. What we do know is that the COVID-19 surcharge is an attempt by practitioners to temporarily compensate for increased expenses. Note that these are not price increases – which would be permanent. Healthcare providers who are implementing the surcharge versus increasing their costs appear to be hopeful that this is a temporary solution for a what is a temporary challenge.

Receive Reimbursement for Diagnosed Malnutrition

Malnutrition has become a major concern over the past few years, especially among the elderly. The incidence of malnutrition in elderly hospitalized patients ranges from 12 to 50% and from 23 to 60% percent among institutionalized senior citizens.

Many elderly Medicare patients, especially those who are severely ill, are malnourished. Malnutrition can result from the treatment of another condition, inadequate treatment or neglect, or the general deterioration of a patients health. Malnourished patients have an increased duration of recovery from their primary illness, often experience increased hospital stays and consume more resources for proper treatment.

Reimbursement to cover additional costs may only be realized if the malnutrition is identified, diagnosed and treated by the physician while providing care for the primary illness. It is imperative for providers to understand the criteria needed to identify document malnutrition in order to maximize nutrition interventions to ensure best outcomes, and also capture reimbursement for the additional care provided.

Medicare sets forth a number of Federal requirements, including the Social Security Act § 1862(a)(1)(A), related to billing for the treatment of severe malnutrition. Hospitals are allowed to bill for the treatment of malnutrition on the basis of the severity of the condition - mild, moderate, or severe, and whether it affects patient care.

Severe malnutrition is classified as a major complication or comorbidity (MCC). Adding an MCC to a Medicare claim can result in a higher Medicare payment because the claim is coded at a higher Diagnosis Related Group.

Currently, the U.S. follows coding criteria set forth by the American Society for Parenteral and Enteral Nutrition (ASPEN). However, the standard clinical criteria for diagnosing severe malnutrition is actively evolving. For now, use the codes below to capture reimbursement for malnourished patient claims.

Proper Coding Results in Reimbursement for All Medicare Annuals and Simultaneous Diagnoses

It used to the be the case that the Medicare program focused on illness-care and chronic disease management. That has changed drastically over the past 8 years as coverage for wellness and preventative-care examinations are now included in Medicare benefits.

However, many providers are still not taking advantage of reimbursement for annual visits. The key behind these not-so-newly covered Medicare benefits is properly coding these wellness visits so that they are covered. Plus, if a patient complains of an additional issue during their annual visit, these should be coded separately and the provider can receive reimbursement for both the annual visit and the problem diagnosis.

Welcome to Medicare Visit

Coding for annual visits for Medicare Part B holders is unique. Billing for a wellness visit is not done using the normal wellness-exam CPT codes (99381-99397). These claims will be rejected as “non-covered services”. Instead, providers should use Medicare-only codes: G0438 for the initial visit and G0439 for subsequent visits.

The Initial Preventative Physical Examination (IPPE), commonly referred to as the “Welcome to Medicare Visit,” is a comprehensive exam a patient can have one time during the first 12 months of having Medicare Part B. The examination consists of seven components:

1. Certain screenings, flu and pneumococcal shots, and referrals for other care, if needed

2. Height, weight and blood pressure measurements

3. Calculation of body mass index (BMI)

4. A simple vision test

5. A review of potential risk factors for depression and level of safety

6. An offer to discuss advanced directives

7. A written plan letting the patient know which screenings, shots, and other preventative services they need

Coding for this initial exam is unique to Medicare. Though the diagnosis code (ICD-10 code) for the exam is Z00.00 (general physical exam), the CPT code for the visit is NOT the wellness-exam code range used by every other insurance plan (99381-99397). Instead, it is billed with a Medicare-only code, G0438.

Subsequent Annual Visits

In addition to the one-time available Welcome to Medicare visit, beneficiaries can also receive an annual wellness and prevention exam with no co-pay. Again, billing for these annual visits will be denied unless they use the Medicare-specific code G0439.

Additional Diagnosis

During their annual visit, a patient may present for a problem or issue unrelated to their wellness exam. For the problem diagnosis, the provider should bill an Evaluation and Management (E&M) code (99202-99204 for new patients or 99212-99215 for established patients) with a modifier 25. If the provider codes the visit and the unrelated problem in this manner, they will be reimbursed for BOTH the E&M and the annual visit. Note that the problem diagnosis would need to be attached to the E&M, while the dx Z00.00 covers the annual.

Providers can receive reimbursement for initial wellness exams, subsequent annual visits as well as simultaneous problem diagnosis if, and only if, all of the services are properly coded. Failure to use Medicare-specific codes for annual and wellness visits will result in denials. And, problem diagnosis that aren’t coded independently and attached to the E&M will not be reimbursed.