The No Surprises Act And Good Faith Estimates

Quest ion:

A patient was given an estimate on 3/20/23 and 4/20/23 for the same upcming service, however the estimates were very different The higher estimate is more accurate in the charges. What is our responsibility in honoring the lower estimate?

Answ er:

The estimate is not a contract, so the patient is still responsible for billed charges. The intent of the estimate is to allow the patient to shop for prices at multiple facilities/providers and have a written document to use should the billed charges exceed that GFE As we discussed, even though the second GFEwas calculated incorrectly and issued in error, it gave the patient the expectation of a lower cost The patient can use that second estimate to initiate a dispute since the billed charges exceeded the second estimate by $400. Fortunately, the error was discovered before they initiated a dispute, so negotiations can occur between the facility and patient outside the formal dispute process

The facility must determine if, and how much, they want to reduce the billed charges to avoid the formal dispute and do service recovery The certified dispute resolution entity fees range in price from $350 - $700. The patient could possibly win the formal dispute costing the facility up to $700 in dispute fees and reimbursing the patient the $25 dispute fee.

More consumer information about the dispute process can be obtained at this link: Dispute a medical bill | CMS

Codes 99406 - 99409

Tobacco Cessation Counseling

Quest ion:

Are there any restrictions when charging codes 99406-99409 during an office visit? Specifically, during pain management or medication assistance therapy when these issues are discussed and documented appropriately.

Answ er:

First, the tobacco cessation counseling There are no CCI edits which prevent billing 99406 or 99407 with an office visit code (99202-99215 ) I have attached our paper on tobacco cessation counseling; the one thing to keep in mind is that Medicare will pay 99406 or 99407 only if a physician or other ?Medicare recognized provider?(ARNP, PA, etc.) provides the counseling.

Our paper offers excerpts and a link and excerpts from Medicare?s National Coverage Determination 210.4, Smoking and Tobacco-Use Cessation Counseling. Here are those codes ? they are reportable by the billing professional and also by the hospital when performed in an outpatient facility setting.

Turning now to alcohol and other non-tobacco substanceabusescreening and counseling: CPT® codes 99408 and 99409 are not covered by Medicare There are special alternate HCPCSto report when providing an alcohol or other non-tobacco substance abuse assessment or counseling

Attached is a CMSMLN document (SBIRTFact Sheet) which summarizes the different codes that may be reported for alcohol and substance abuse assessments and interventions, which are reported with HCPCSG2011, G0396, or G0397.

In addition, Medicare beneficiaries are eligible for preventive screening and counseling services which cover alcohol abuse alone (without other substances or tobacco ) Qualified providers and facilities can report G0442 (ANNUAL ALCOHOL MISUSESCREENING, 5 TO 15 MINUTES) once annually, and for those who screen positive, G0443 (BRIEFFACE-TO-FACE BEHAVIORAL COUNSELING FORALCOHOL MISUSE, 15 MINUTESup to four times annually.

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