Medicare for Medical Coder/Biller - dummies

Medicare for Medical Coder/Biller

Four types of Medicare exist — Parts A through D — and each serves a particular purpose, which makes it complicated for medical coding and billing. The different types of Medicare and the fact that participation is automatic in some cases but not in others can lead to a lot of confusion with the plan’s beneficiaries.

Make sure you verify exactly which parts of Medicare are applicable to the patients you’re dealing with before services are provided.

Medicare Part A

Medicare Part A covers expenses for inpatient care in hospitals, skilled nursing facilities, hospice, and home healthcare.

Spending the night in a hospital does not necessarily mean that the visit is a Part A claim. The patient must have been admitted under physician orders to be an inpatient.

Medicare Part B

Medicare Part B helps pay for services deemed medically necessary. These services include physician services (including some preventative services like flu shots), outpatient visits, durable medical equipment, and home health services. Beneficiaries must enroll in Part B, and they pay a monthly premium. In addition, beneficiaries are responsible for paying an annual deductible and 20 percent co-insurance for Medicare-eligible services.

Some patients do not realize that Part B is optional, and they may mistakenly believe that they have it simply because they qualify for Medicare. Make sure you see the patient’s Medicare card to verify Part B benefits.

Medicare Part C

Medicare Part C refers to replacement plans that some patients opt to enroll in. These replacement plans are offered by Medicare–approved private companies. Medicare replacement plans cover Part A and Part B services. Some plans also offer drug and vision coverage as well.

Medicare pays a fixed amount each month to companies that offer replacement plans, and in return, the companies agree to follow the rules set by Medicare for administration of the replacement plans. Each plan can charge out-of-pocket costs and can establish rules for plan use, such as requiring referrals to see specialists or requiring that the patient see only network providers.

Medicare-eligible patients who prefer private insurance enroll in Part C replacement plans. Some larger companies who historically have allowed retiring employees to stay on the company health plan are now offering Part C replacement plans to eligible enrollees. Some companies with employees who are Medicare eligible offer these employees Part C plans as well.

When coding for services provided to these patients, make sure that you verify coverage and plan restrictions prior to any encounter. Commercial plans follow commercial contract obligations, and the Medicare plans have to follow Medicare payment guidelines unless the commercial contract contains a Medicare Part C reimbursement clause that obligates the payer to a specific payment or fee schedule different than standard Medicare.

You can avert unnecessary appeals by verifying Part C enrollment early in your coding process. Verification of Medicare patients is fairly simple. Some of the Medicare contractors have websites that let providers check patient benefits. Others have interactive voice response (IVR) telephone systems that providers can call to check patient coverage.

Medicare Part D

Medicare Part D is Medicare’s prescription drug plan. Medicare-approved companies run these plans. To participate, qualifying individuals must enroll in a plan and adhere to plan restrictions.

Part D normally does not affect healthcare providers or their staff. But some patients can be confused and think they’ve enrolled in a Medicare supplement when what they have is a Part D plan to cover prescription drugs. In these situations, you may find yourself explaining to the patient the difference between another major medical plan and a Medicare supplement plan.