Plan N copay for chemo?
- Thread starter GreenSky
- Start date
- 2,370
Exactly right with this thread...it all depends on what codes the billing department uses for the visit. Unfortunately, you may not know until after the fact. Some billing departments do the "ask for forgiveness" method...
- 5,778
The reason for my question... I have spoken to many men who have had prostrate cancer treatment that has included as many as 60+ visits for treatment. Doing the math, that's an additional potential out of packet of $1200... bringing me to my next point. Recently on a thread there was the discussion of additional coverage through a cancer plan... and here is an example of why that type of coverage is important even in situation when medicare is involved.
- 6,455
For the situation which you describe, wouldn't an agent want to sell a plan G instead of a plan N first, and then add cancer coverage?
Given the situation which you describe and the characteristics of plans G and N, it seems like stacking a cancer plan on top of a plan N for the purpose you describe is misusing additional funds spent for the cancer coverage.
If I was an agent, I would be somewhat uncomfortable selling an N plus cancer combination rather than a G plus cancer combination.
(If it was my own personal buying decision, I would buy an HDF + cancer before I would buy an N + cancer.)
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For established patients, the office visit (Evaluation and Management) CPT codes range from 99211 (brief) to 99215 (lengthy). These codes are subject to the Plan N copay.
The Medicare allowable for the chemotherapy administration code already accounts for a brief visit on that day. If the patient reports no additional issues, it should be a brief visit and the provider should not bill 99211. This means no Plan N copay. If the patient reports an issue, additional time will be needed and the provider can bill 99212-99215 which are subject to the Plan N copay.
Plan N codes subject to copay: https://www.cms.gov/Medicare/Health-Plans/Medigap/downloads/Plan_N_Guidance2.pdf
Medicare Claims Processing Manual, Ch.12, Section 30.6.7.D - Drug Administration Services and E/M Visits Billed on Same Day of Service:
MACs must advise physicians that CPT code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or nonchemotherapy drug infusion code (effective January 1, 2004). This drug administration policy was expanded in the Physician Fee Schedule Final Rule, November 15, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005).
Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.
The Medicare allowable for the chemotherapy administration code already accounts for a brief visit on that day. If the patient reports no additional issues, it should be a brief visit and the provider should not bill 99211. This means no Plan N copay. If the patient reports an issue, additional time will be needed and the provider can bill 99212-99215 which are subject to the Plan N copay.
Plan N codes subject to copay: https://www.cms.gov/Medicare/Health-Plans/Medigap/downloads/Plan_N_Guidance2.pdf
Medicare Claims Processing Manual, Ch.12, Section 30.6.7.D - Drug Administration Services and E/M Visits Billed on Same Day of Service:
MACs must advise physicians that CPT code 99211 cannot be paid if it is billed with a drug administration service such as a chemotherapy or nonchemotherapy drug infusion code (effective January 1, 2004). This drug administration policy was expanded in the Physician Fee Schedule Final Rule, November 15, 2004, to also include a therapeutic or diagnostic injection code (effective January 1, 2005).
Therefore, when a medically necessary, significant and separately identifiable E/M service (which meets a higher complexity level than CPT code 99211) is performed, in addition to one of these drug administration services, the appropriate E/M CPT code should be reported with modifier -25. Documentation should support the level of E/M service billed. For an E/M service provided on the same day, a different diagnosis is not required.
What he said.
- 591
Great stuff. The argument for additional coverage like Cancer, Heart Attack, Stroke and Hospital Indemnity will go around and around. The truth is that you'll never identify all the potential gaps in coverage nor should the client be looking to cover every single gap. All we can do is present what is available and let them make the decision based on their needs and wants.
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