Medicare billing

Can a physician who is not credentialed by Medicare because the credentialing is pending, bill Medicare for services performed in the CCU? Credentialing was approved, but not retroactive back to his first date of service. If he can, is there a modifier that needs to be used?

re: MEDICARE BILLING

No, he cannot

re: MEDICARE BILLING

I understand your physician is still being credentialed but I wanted to suggest you review your contractor provider manual this may not apply to you but many of my providers have opted out and wanted to know could they be paid in emergent situations so I had to research and found the below in my contractor (Cahaba) provider manual. Again, I understand this may not apply to you but I hope you will contact your contractor or reference your contractor provider manual for specific guidance I am just thinking if there is a portion of the manual to address opted out providers and emrgent situation there may be one to address your situation specifically and if not, at least you have performed due diligence in researching nevertheless, here is the info from my provider manual regarding opted out providers and emergent situations:

GJ Opted Out physician or practitioner - Use to indicate services performed in an emergency or urgent service.

40.28 - Emergency and Urgent Care Situations (Rev. 1, 10-01-03)
B3-3044.28

Payment may be made for services furnished by an opt-out physician or practitioner who has not signed a private contract with a Medicare beneficiary for emergency or urgent care items and services furnished to, or ordered or prescribed for, such beneficiary on or after the date the physician opted out.
Where a physician or a practitioner who has opted out of Medicare treats a beneficiary with whom the physician or practitioner does not have a private contract in an emergency or urgent situation, the physician or practitioner may not charge the beneficiary more than the Medicare limiting charge for the service and must submit the claim to Medicare on behalf of the beneficiary for the emergency or urgent care. Medicare payment may be made to the beneficiary for the Medicare covered services furnished to the beneficiary.

In other words, where the physician or practitioner provides emergency or urgent services to the beneficiary, the physician or practitioner must submit a claim to Medicare, and may collect no more than the Medicare limiting charge in the case of a physician, or the deductible and coinsurance in the case of a practitioner. This implements §1802(b)(2)(A)(iii) of the Act, which specifies that the contract may not be entered into when the beneficiary is in need of emergency or urgent care. Because the services are excluded from coverage under §1862(a)(19) of the Act only if they are furnished under private contract, CMS concludes that they are not excluded in this case where there in no private contract, notwithstanding that they were furnished by an opt-out physician or practitioner. Hence, they are covered services furnished by a nonparticipating physician or practitioner, and the rules in effect absent the opt-out would apply in these cases. Specifically, the physician or practitioner may choose to take assignment (thereby agreeing to collect no more than the Medicare deductible and coinsurance based on the
who would bill Medicare using the post op only modifier to be paid for the post op care in the global period.

If the beneficiary continues to be in a condition that requires emergency or urgent care (i.e., unconscious or unstable after surgery for an aneurysm) follow up care would continue to be paid under emergency or urgent care until such time as the beneficiary no longer needed such care. In the absence on controvertible evidence CMS recommends accepting what the physician or practitioner says via the modifiers and doing post-pay records review of frequent users of the opt-out modifier.

40.29 - Definition of Emergency and Urgent Care Situations (Rev. 1, 10-01-03)
B3-3044.29

Emergency services are defined as being services furnished to an individual who has an emergency medical condition as defined in 42 CFR 424.101. The CMS has adopted the definition of emergency medical condition in that section of the Code of Federal Regulations (CFR). However, it seemed clear that Congress intended that the term “emergency or urgent care services” not be limited to emergency services since they also included “urgent care services.” Urgent Care Services are defined in 42 CFR 405.400 as services furnished within 12 hours in order to avoid the likely onset of an emergency medical condition. For example, if a beneficiary has an ear infection with significant pain, CMS would view that as requiring treatment to avoid the adverse consequences of continued pain and perforation of the eardrum. The patient’s condition would not meet the definition of emergency medical condition because immediate care is not needed to avoid placing the health of the individual in serious jeopardy or to avoid serious impairment or dysfunction. However, although it does not meet the definition of emergency care, the beneficiary needs care within a relatively short period of time (which CMS defines as 12 hours) to avoid adverse consequences, and the beneficiary may not be able to find another physician or practitioner to provide treatment within 12 hours.

§ 424.101 Definitions.
As used in this subpart, unless the context indicates otherwise— Emergency services means inpatient or outpatient hospital services that are necessary to prevent death or serious impairment of health and, because of the danger to life or health, require use of the most accessible hospital available and equipped to furnish those services.

§ 42 CFR 405.400
Urgent care services means services furnished to an individual who requires services to be furnished within 12 hours in order to avoid the likely onset of an emergency medical condition.

Best Wishes!