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Harmed Patient Protocol Form
POSTED OCTOBER 22, 2007
From Billie L.
Jackson, MD:
The pathology bill
hearing to oppose direct billing for Dermatologist will be heard
this Friday, October 26 at 1:00 p.m. in
Atlanta (at the Capitol). We need several dermatologists to
testify in opposition to the proposed bill. Please send out an email to
all members and ask for volunteers. Especially anyone performing direct
billing that is showing a savings to patients for doing so.
Explanation
of bill and the GSD's position - Rhonda Rogers, MD:
The GSD echoes the AAD's
policy of permitting both direct billing and client billing. Most of the
members of GSD direct bill; ie, they bill the patient for the biopsy but
do not bill the patient for the reading of the slide...they have their
designated pathologist read the slide and bill the patient directly. In
this scenario, both the dermatologist and the pathologist "direct bill."
If this present bill were to pass, this would be the only scenario that
would be legal.
A minority of dermatologists in
Georgia offer their patients "client billing" and bill their
patients both for the service they themselves provide as well as for the
cost of the pathology service. These dermatologists have contracted with
a pathology lab (actually vice versa), and the pathologist pays the
dermatologist a certain amount for each slide read. This scenario is what
the pathology group is trying to make illegal - ironic since they initiate
the contract in the first place.
The term "direct billing" is notoriously confusing. The pathologists are
wanting direct billing so they can bill the
patient directly for the service that they provide, ie, reading the
slide. Client billing involves dermatologists
charging patients for pathologists’ services that were performed by
pathologists. So as I understand it, "client billing" and "pass through
billing" are the same and differ from direct billing.
At this website,
http://www.skinandaging.com/article/4239,Inga
Ellzey in 2005 makes the distinction this way:
Billing Scenarios
Basically, four scenarios represent how dermatology practices
bill with respect to pathology services. They are:
1. No billing for pathology services. In this scenario, the practice sends
tissue specimens to an outside reference lab that performs both the
technical and professional services (referred to as the global service)
and bills the insurance carriers or patients directly.
In this scenario, there is no “pass-through” billing. Pass-through billing
means that the dermatology practice buys the service(s) from a lab at a
discounted price, marks up the cost of the service(s), and then passes the
increased charge on to the patient or insurance carrier through direct
billing from the practice.
2. Pass-through billing. Here, the practice makes money by purchasing the
technical component, the professional component, or both. The practice
marks up the cost of the purchased service and passes the increase on to
the patient or insurance company by billing the pathology service(s)
directly to the insurance company.
Some carriers are now establishing up policies that prohibit practices
from pass-through billing. Some states have anti-mark up legislation in
effect prohibiting physicians from making money by marking up purchased
laboratory and/or pathology service. Medicare does not allow pass-through
billing.
3. Purchased service billing. Medicare allows the physician to purchase
the technical component of the pathology services from an outside
reference laboratory. The purchasing of the technical component is only
allowed if the practice reads its own slides. In this scenario, there are
two options:
a. The technical component is billed by the laboratory and the
practice only bills for the professional component.
b. The technical component is billed by the physician who
purchases it. In this scenario, the physician can bill Medicare only the
exact amount charged to the practice for the technical component by the
outside lab. In other words, if the laboratory charges $10 for the slide
prep, then the practice can only bill Medicare $10 for the technical
component.
• No mark-ups are allowed.
•The technical component must be billed on a separate claim
form. It can’t be billed on the same claim form that contains the billing
for the professional component.
• No global billing is allowed if either component is
purchased. Global billing refers to billing the pathology service with no
modifiers.
4. Global billing. In this scenario, the practice has its own in-house
laboratory, a High-Complexity CLIA certification, and not only employs
physicians who read the slides, they also make their own slides. No
portion of the pathology service is purchased.
Billing is done directly from the practice and no modifiers are needed
when billing for pathology services.
Billing Myths and Musts
In this section, some billing myths and musts are covered that should
guide billers to quality billing for these types of services.
1. Myth: The codes are subject to the multiple surgery reduction rule.
This is incorrect. These are laboratory services and are not subject to
any reductions. Each service will be paid at 100% of the allowed amount
regardless of the number of services billed.
2. Myth: The codes have an associated post-op period. There is no global
period associated with these services. Therefore, no global modifiers are
required. If other services are billed (such as surgery or E/M visits) and
these are billed during the postoperative period, a -24 or -79 modifier is
required. Pathology services are not subject to global periods and
therefore do not require post-op modifiers.
3. Must: These codes are billed in units if multiple services are
performed on the same date of service.
Example: Four slides are read; the diagnoses are 702.0, 173.3, 173.2, and
216.5. The practice bills globally. You would bill:
88305 x 4 units (only one of the four diagnoses needs to be listed in
block 24E regardless that not all four share the identical diagnosis).
4. Myths about the difference between CPT codes 88304 and 88305. Some
practices have misunderstood the application of these codes. These
misapplications include:
a. Using 88304 when the diagnoses are benign and 88305 when the diagnosis
is malignant. Wrong! The diagnosis has nothing to do with the code
selection.
b. Using 88304 when only one slide is ordered and using 88305 when more
than one are ordered for the same patient for the same date of service.
Wrong! The number of slides obtained has nothing to do with code
selection.
c. Using 88304 when the service is purchased and 88305 when the service
is performed solely in-house. Wrong! How services are billed, whether
purchased or not, have already been covered earlier in the article.
5. Myth: You must bill the purchased service in the geographic payment
locality where the service was performed. Effective Oct. 22, 2004,
Medicare has implemented a temporary change in carrier jurisdictional
pricing rules of purchased diagnostic services. The change allows
physicians purchasing out-of-jurisdiction tests and interpretations to
bill their local carrier for these services. They no longer have to bill
the service based on the point of service.
6. Myth: You can bill for consultations performed by outside consultants.
It is not uncommon for physicians who read their own slides to
occasionally have a second opinion ordered on a challenging or
questionable slide. Frequently, these dermatopathologist consultants are
in another state and are usually not signed up with the carriers with
which the group has contracts. The consulting physician usually does not
want to get involved in billing the patient or the patient’s insurance
carrier. Consequently, they just send a bill to the physician who ordered
the consultation.
The consults are usually expensive and so the ordering physician wants to
get reimbursed for the cost of the dermpath consultation. So he/she just
bills the consultation using his name and provider number. This is not
allowed by Medicare whatsoever.
Other carriers consider it pass-through billing while others even consider
this practice fraud because the provider doing the billing for the service
did not actually perform the service and is misrepresenting the services
by billing for it under his/her name and provider number.
POSTED OCTOBER 10, 2007
Update letter to GSD
Membership from GSD President Rhonda Rogers emailed and mailed
CLICK HERE IF YOU MISSED IT
POSTED MARCH 13, 2006
Subject: AAD Synergy Summit
Reported by: Stuart M. Goldsmith, M.D., GSD President
The AAD Synergy Summit, held February 3-4 in Orlando, brought together
state society presidents with national leaders to discuss issues in the
areas of quality of care initiatives, scope of practice, and ethics in
medical care. My impression of some high points includes:
Quality of Care: Be on the lookout for performance requirements,
e.g., documentation of total skin exam and lymph node exam in patients
with a history of melanoma. Some type of “pay for performance”
requirements are going to be implemented, and it could only be in our
interest to be involved in the development of these requirements.
I urge everyone to read Dr. Hood’s review, in the Feb., 2006 American
Board of Dermatology newsletter, of the changes on the horizon for
dermatologists’ maintenance of certification, including a closed book
examination beginning in 2006. Many changes are mandated from the national
specialty certification body.
Continuum/Scope of Practice: Whether in regards to PA training and
scope of practice or non-dermatologists, including non-physicians,
performing dermatology procedures, dermatologists must set high standards
of patient care and educate the public about our training and
expertise. Other societies, e.g. physician assistant societies, are
organized and aggressively promoting their agendas. The AAD logo, for
example, can be utilized more in offices, advertisements, communications,
and educational settings as a means of differentiating our qualifications.
Ethics in Medical Care: Guidelines may be developed in regards to
patient notification of conflicts of interest as well as pathology billing
mark-up. More disclosure regarding ghost writers was also recommended. In
addition, the AAD policy already in place regarding physician assistant
supervision should be re-emphasized. This policy states that the
supervising physician should see each new patient and each established
patient with a significant new problem. A PA to physician ratio maximum of
2:1 was also supported.
This summit emphasized the importance of involvement at the state level,
as much of the legislation that directly affects our patients and our
practices is created and enforced at the state level. There has been
Georgia legislation discussed this year involving tanning bed regulation,
pathology billing, laser supervision, and scope of practice/prescribing
privileges. Though the pathology issue saw physicians in disagreement,
with the other issues there are non-physicians, with their own agendas,
lobbying hard for positions that may not be in our patients’ interests. If
there is not an organized response, our patients and our specialty will
suffer. Whether through the Medical Association of Georgia, the Atlanta
Dermatology Society, and, hopefully, to an increasing extent this society,
I encourage every dermatologist in Georgia to become informed, get
involved and to get others involved.
POSTED MARCH 9, 2006
Subject: Tanning Bed Legislation
Tanning bed legislation providing structure
and regulation that the GSD
supports went before a House committee hearing on Wednesday,
March 8, 2006. Dr. Stuart Goldsmith, GSD President, was in
attendance and presented in favor of the bill.
The bill was tabled.
Comments from Dr. Goldsmith:
There were, I think, some legitimate concerns about
administration and funding (though I may be giving the committee an
undeserved benefit of the doubt, concerning the politics involved). Rep.
Drenner is committed to getting this legislation passed and she has done a
lot of research, including review of each state’s legislation. She had,
apparently, kept asking MAG to get dermatology input. I only became
involved after I contacted her office to find out about the status of the
legislation, which was introduced last March. I wish I had asked months
ago. Nonetheless, each step may get us closer to getting something
worthwhile passed. I hope getting some legislation passed is a major goal
for next year. We, obviously, need to get others involved, particularly
AAD and MAG. I will try to talk soon with Larry Lanier at AAD. Other
organizations, e.g., Pediatrics and Family Practice, would also, I would
think, support a more effective legislation. Currently, the only
requirement is that consent must be obtained for those under 18, and I
think that requirement is often ignored.
POSTED FEBRUARY 9, 2006
Subject:
American Society for Dermatologic Surgery (ASDS) Non-Physician Practice of
Medicine Campaign
To Georgia Society of
Dermatologists
Due to the
proliferation of spas, salons and walk-in clinics,the American Society for
Dermatologic Surgery has noted an increase in legislation across the
country allowing certain cosmetic procedures to be performed by
non-physicians. This email is being sent to you to raise your level of
awareness of this growing trend and to let you know the ASDS can be a
resource to you should you need to respond to legislation proposed in your
state. The ASDS has launched a campaign warning legislators that cosmetic
treatments, such as those using lasers, high-tech light devices, chemical
peels, soft tissue fillers, botulinum toxin are medical/surgical
procedures that should be performed by a fully qualified physician or
under the direct supervision of the physician.
One example of a bill
threatening patient safety is Virginia House Bill 1399. The bill would add
a "laser light technician" to the Board for Barbers and Cosmetology. The
bill states that the regulation of laser or light therapy technicians will
be approved by the Board for Barbers and Cosmetology. The bill further
defines laser or light therapy as the "nonabrasive photo-rejuvenation of
the skin or the removal of hair by selective photothermolysis, using laser
or light therapy devices." Fortunately, the bill was sent back to
committee and will be carried over until next year.
Not only is ASDS
involved in tracking legislation on this issue but we are also pursuing
cases where non-physicians are performing medical procedures illegally. In
California ASDS established a working relationship with the Medical Board
of California to jointly pursue enforcement actions against non-physicians
performing these illegal procedures. ASDS is also compiling evidence it
has received in
California and submitting
these records to the state regulatory agencies and local public attorney
civil-consumer protection units for pursuit.
It is ASDS’s position
that under the appropriate circumstances, a physician may delegate certain
procedures to certified or licensed non-physician office personnel (e.g.
RN, CMA, LPN, PA, NP, CORT). Specifically, the physician must directly
supervise the non-physician office personnel to protect the best interests
and welfare of each patient. The supervising physician shall be physically
present on-site, immediately available, and able to respond promptly to
any question or problem that may occur while the procedure is being
performed. It is the physician’s obligation to ensure that, with respect
to each procedure performed, the non-physician office personnel possess
the proper training in cutaneous medicine, the indications for the
procedure, and the pre- and post-operative care involved.
Please note that
legislation delegating cosmetic procedures to non-physicians could be
underway in your state. As you know, the best way to defeat these bills is
to have your association respond quickly to your state legislators voicing
your opposition to the bill.
Do not hesitate to
contact Ted Thurn, Advocacy and Socioeconomic Affairs Manager at
tthurn@asds.net with any questions you may have.
Sincerely,
Darrell S. Rigel, MD
ASDS Scope of Practice
Work Group
POSTED JANUARY 24, 2006
Subject: Proposed Laser Rules
There is an important issue on which the GSD needs to get
active. The Composite State Board of Medical Examiners has issued a
"Notice of Intent to Amend and Adopt Rules" regarding who can operate
laser equipment and the definition of "physician supervision". The
Atlanta Dermatological Association has officially responded and will be
present at the public hearing on February 2.
The hearing will begin at 8:30 a.m. on Thursday,
February 2, 2006 at the
DCH Board Room, 40th Floor, 2 Peachtree Street, NW, Atlanta, Georgia
30303, to
provide the public an opportunity to comment upon and provide input into
the proposed rules. The Board will consider at this meeting, whether
the formulation and adoption of this proposed rule amendment imposes
excessive regulatory costs on any licensee or entity and whether any cost
to comply with the proposed rule amendment could be reduced by a less
expensive alternative that accomplishes the objectives of the statutes
which are the basis of the proposed rule.
It is requested that GSD members, in particular, those also members of
the Atlanta Dermatological Association, attend the hearing as
representatives of the GSD. Of course, all GSD members are
encouraged to attend the hearing.
Harold Brody, MD, Scott Karempelis, MD, Alex Gross, MD and Mack Rachal, MD
will speak at the public forum. The AAD representative Rob Bohannon
will also speak on the behalf of the AAD.
Find the Proposed Laser Rule at the following link:
Proposed Laser Rules
Find the Atlanta Dermatological Association's response to
the proposed laser rules and position statement at the following link:
Atlanta Dermatological
Association Response
Please make every
effort to attend the hearing! |
