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Refunding Copays; Defining Calendar Month; Proper Documentation


Coding questions? We've got the answers.

Refunding Copays

Q: Last year our OB/GYN front-office staff diligently collected copays on preventive visits according to the patients' insurance cards. Somewhere along the way, insurance companies started reimbursing us at 100 percent of our contracted rate and not subtracting the copay. We now have some $60,000 in copays that we think have to be refunded to the patients. Is this correct? We stopped collecting copays because it will be extremely time consuming to write thousands of $10 to $20 checks, and we do not want to deal with any more refunds. I know one other practice has a similar problem and I am wondering if this is a nationwide issue.

A: This is an interesting question with two facets. First, I am wondering why payers are reimbursing you 100 percent when their contracts with their beneficiaries call for copays. Have you asked them?

The second issue is that you now have what would be termed a credit balance. I believe in North Carolina the law is that you have one year to get that balance back to a patient, in the form of a check or as a credit on a balance. The odd part is that if you don't get it back to the patient within that duration, those funds need to be given to the state.

My recommendation is to ask your biggest payers why they are reimbursing at 100 percent. Be sure to send your inquiry in writing so you have it recorded. I would also ask a healthcare attorney about the credit balances

Defining Calendar Month

Q: I have a question about the transition of care management (TCM) codes 99487 and 99489. The CPT manual says: "First hour of clinical staff time directed by a physician or other qualified healthcare professional with no face to face, per calendar month." I'm wondering when a calendar month starts and ends. For example: We have a patient that was discharged from the hospital on March 13 and our nurse called the patient on March 17 to start a coordination of care over the phone. For billing purposes, would the end of month be March 31, April 13, or April 17 (since March 17 was the initial nurse/patient contact)?

A: By calendar month they mean January, February, March, etc. In your example you started care coordination on March 17. If by March 31 you have 30-plus minutes of coordination, then on April 1 you can bill one unit with date of service as April 1.

If you don't get at least 30 minutes of coordination completed by March 31, you lose the opportunity to bill for any of that coordination because the cycle starts over in April. The calendar month doesn't mean 30 days worth of care coordination services; it's more about what you do in a given calendar month.

TCM and Date of Service

Q: I have been reading about the requirements for the transitional care management (TCM) services. I still don't understand what is billed, when?

A: Join the crowd. I haven't seen this much confusion regarding codes in a long time. Just today a Medicare service representative told a provider to bill the seven-day or 14-day E&M visit, and then wait a month to bill the TCM code 99495 or 99496. Please don't do that.

The TCM codes represent 30 days worth of post-hospital follow-up. They include, among other things, contacting the patient within two business days of discharge, and a face-to-face visit within either seven days or 14 days, depending on which code you bill for. You do not bill for that E&M visit, it is part of the TCM service.

You will not use that date of service for the TCM code. The TCM code is billed with the date of service that is the 30th post-discharge day and the claim is then submitted, either that day, or a subsequent day. You are using a date of service for the claim on a day that the patient is not in the office, and may not have been in the office for three weeks. That is what seems to befuddle most billers, office managers, and providers. If you use the visit date with the TCM code it will be denied.

Bill Dacey, CPC, MBA, MHA, is principal in the Dacey Group, a consulting firm dedicated to coding, billing, documentation, and compliance concerns. Dacey is a certified coding instructor and has been active in physician training for more than 20 years. He can be reached at or

This article originally appeared in the July-August 2013 issue of Physicians Practice.

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