Sat. Feb 4th, 2023

As an outsourced medical billing company I get many questions regarding Medicare. I will keep track of these questions and publish some of them periodically in one of my articles. Below are answers to three commonly asked questions.

Do Medicare rules apply to patients who don’t have Medicare?

Medicare has rules called “conditions of participation” regarding facilities and home care agencies and these rules apply whether or not the patient has Medicare. In order for the facility to maintain its Medicare provider status, it must meet the conditions of participation. On the other hand, Medicare only stipulates that these rules only apply to Medicare patients and do not have any connection with other payers. So if there is a patient that comes in for an office visit and they do not have Medicare or any other type of insurance and will be paying for the visit themselves, the provider does not have to accept Medicare’s rates and does not have to meet Medicare’s required documentation or disclosure requirements or Medicare’s performance measures.

What constitutes an “Initial Visit” for Medicare billing?

For example, if a patient comes into the office to receive results of a sleep study can this be billed as an initial visit? An initial visit or a “new patient” visit is a face-to-face visit. If you are going over and giving the results of the sleep study with the patient present and have given further instruction and have a treatment plan, this is an initial visit. If the patient is not present when giving the results, then this is not a visit. According to Medicare, a patient qualifies as a new patient when they have not been seen in over 3 years. If the patient has not been seen for over 3 years, an initial visit can be billed. If a patient visits the hospital, then one initial visit per patient per hospitalization is allowed. All other visits while the patient is hospitalized are to be billed as subsequent visits.

Can more than one Nurse Practitioner bill a Medicare patient on the same day?

In some cases this is allowed. For example, if there are two Nurse Practioners one being the primary care nurse that bills Medicare one diagnosis and the other Nurse Practioner being in a specialty practice bills for a different diagnoses on the same day. Will the bills for these visits through two separate practices and two separate provider numbers be paid by Medicare? Yes. According to Medicare rules, both claims would be paid. The reason they will be both paid is due to their being two different diagnoses on each claim and the bills are being generated by two separate providers. However, when there are cases of two Nurse Practitioners who have billed for the same day with the same diagnosis, it is likely that one of these claims will be rejected by Medicare. In this case, it is extremely important that the Nurse Practitioner has justification through their progress notes to back up their claim.