Medical Coding and Billing Articles

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ICD-11 — What’s Happening?

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ICD-11 is officially released, but what does that mean for diagnosis coding in the United States? What's really different? This article discusses what has been happening with ICD-11, some interesting things to note about it, as well as links to other important information.

tags  Specl: All Specialties    Topic: Diagnosis Coding    Topic: ICD10CM Coding    Topic: Practice Management   

Q/A: For E/M, How do I Count Tests Ordered in One Department and Performed in Another?

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Question: I am in an ENT office as part of a large clinic with separate practices including audiology, CT, and allergy, all billing under the same TAX ID. Sometimes tests are ordered which are done in other departments that my office does not bill for, would those be considered an outside source? Answer: This is a great question and one that has been asked by many coders and auditors.

tags  Loc: All Locations    Payer: All Payers    Specl: All Specialties    Topic: Coding    Topic: CPT Coding    Topic: E+M Documentation and Coding    Topic: Procedure Coding   

Failure to Follow Payer’s Clinical Staff Rules Costs Provider $273K

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Clinical staff (e.g., LPN, RN, MA) provide essential services which allow providers to leverage their time and improve reimbursement opportunities and run their practices more efficiently. There is, however, an ongoing question of how to appropriately bill for clinical staff time. This is really a complex question which comes down to code descriptions, federal or state licensure, AND payer policies. Failure to understand licensing and payer policies led a Connecticut provider organization down a path that ended in a $273,000 settlement with both federal and state governments.

tags  Topic: Billing    Topic: Compliance    Topic: Modifier Coding   

58% of Improper Payments due to Medical Necessity for Ventilators

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Proper documentation not only protects the provider, the payer, and the patient, it protects the integrity of the entire healthcare system. When it comes to coverage and documentation for durable medical, the DMEPOS supplier and staff must be familiar with the National and Local Coverage Determinations (NCDs and LCDs) as these are ...

tags  Specl: Home Health|Hospice    Topic: DME    Topic: HCPCS Coding    Topic: ICD9 Coding   

Coding Lesions and Soft Tissue Excisions

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There are several considerations to be aware of before assigning a code for lesions and soft tissue excisions. The code selection will be determined upon the following: Check the pathology reports, if any, to confirm Morphology (whether the neoplasm is benign, in-situ, malignant, or uncertain) Technique Topography (anatomic location) The size Tissue Level Type of closure required Layers ...

tags  Specl: Dermatology|Plastic Surgery    Specl: Primary Care|Family Care    Topic: CPT Coding    Topic: Modifier Coding   

Properly Reporting Imaging Overreads (Including X-Rays)

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hile many provider groups offer some imaging services in their offices, others may rely on external imaging centers. When the provider reviews images performed by an external source (e.g., independent imaging center), that is typically referred to as an overread or a re-read. Properly reporting that work depends on a variety of factors as discussed in this article.

tags  Specl: Radiology    Topic: Billing    Topic: Coding    Topic: CPT Coding    Topic: E+M Documentation and Coding    Topic: Modifier Coding    Topic: Procedure Coding   

Why Will Medicare Administrative Contractors be Holding Claims Up?

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When Congress passed the expansive American Rescue Plan Act last month, most Americans were focused on the direct payment provision of the bill. However healthcare administrators and policymakers had their attention on another aspect: cuts to Medicare payments. Why would Congress be cutting Medicare payments during the COVID-19 Public Health ...

tags  Payer: CMS|Medicare    Specl: All Specialties   

Evaluation & Management (E/M) Webinar Q/A

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Find answers to some questions asked by attendees of our recent webinar regarding the changes released by the AMA in their March 9, 2021 Errata and Technical Corrections document in relation to Evaluation & Management (E/M).

tags  Specl: All Specialties    Topic: CPT Coding    Topic: E+M Documentation and Coding    Topic: Modifier Coding   

Understanding Skin Biopsy Codes

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A biopsy is a procedure to obtain only a portion of a lesion for a pathologic exam. According to the AMA, "The use of a biopsy procedure code (e.g., 11102, 11103) indicates that the procedure to obtain tissue for pathologic examination was performed independently, or was unrelated or distinct from other ...

tags  Specl: Dermatology|Plastic Surgery    Topic: Codapedia    Topic: Coding    Topic: CPT Coding   

How Reporting E/M Based on Time May Lose Money

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Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...

tags  Loc: All Locations    Payer: All Payers    Specl: All Specialties    Topic: CPT Coding    Topic: Documentation    Topic: E+M Documentation and Coding    Topic: Physician Billing   

The OIG Turns their Gaze to Possible Inpatient Service Upcoding

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The Office of Inspector General for the United States Department of Health and Human Services (HHS-OIG) is responsible for ensuring the integrity of programs operated by HHS, including the Medicare and Medicaid programs. One of the ways this is accomplished is through the identification of fraudulent activities, one of which ...

tags  Payer: CMS|Medicare    Topic: Auditing    Topic: OIG   

Critical Evaluation and Management Changes Recently Announced by AMA

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On March 9, 2021, the American Medical Association (AMA) announced some pretty significant changes in relation to reporting Evaluation and Management (E/M) services, particularly for Office or Other Outpatient Services (99202-99215). The AMA Editorial Panel had previously met to discuss how to address concerns and made changes surrounding Office or Other Outpatient Services which are retroactive to January 1, 2021. Learn more about those changes in this article.

tags  Specl: All Specialties    Topic: Code Updates    Topic: CPT Coding    Topic: E+M Documentation and Coding    Topic: Procedure Coding   

COVID-19 Vaccines

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To accommodate the new COVID-19 immunizations the CPT editorial panel has approved 11 Category I codes. Watch for new and revised guidelines and parenthetical notes with these codes. For example; which administration codes should be used with the vaccine codes and the NCD codes applicable to the dose being administered. These ...

tags  Topic: COVID-19    Topic: CPT Coding    Topic: HCPCS Coding   

COVID Vaccinations — FREE Legal and Ethical Considerations Webinar

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Learn about legal and ethical implications of the COVID-19 vaccine with this free webinar held on Wednesday, February, 24, 2021.

tags  Specl: All Specialties    Topic: COVID-19   

Why CMS Created G2212 for Prolonged Services Instead of 99417

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This article discusses WHY CMS decided to create code G2212 to be used with prolonged office Evaluation and Management (E/M) services instead of code 99417 as of January 1, 2021. The proposed Medicare Physician Fee Schedule stated that code 99417 would be used so it is essential to understand why they made this change to avoid potential problems with billing these services.

tags  Specl: All Specialties    Topic: CPT Coding    Topic: E+M Documentation and Coding    Topic: HCPCS Coding    Topic: Procedure Coding   

How To Properly Report Prolonged Services Using 99417 or G2212

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Prolonged Evaluation & Management codes underwent big changes in 2021, including the creation of a new prolonged code (99417), reportable only with codes 99205 or 99215. While Medicare has agreed to accept the AMA's CPT E/M coding changes, they have formulated an opinion contrary to how CPT calculates time specific ...

tags  Specl: Acupuncture|Alternative    Specl: All Specialties    Specl: Anesthesia|Pain Management    Specl: Behavioral Health|Psychiatry|Psychology    Specl: Cardiology|Vascular    Topic: CPT Coding    Topic: E+M Documentation and Coding    Topic: HCPCS Coding    Topic: Procedure Coding   

AMA Announcement of Additional COVID Vaccine Codes and Guideline Changes in December

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On Friday, December 17, 2020, the AMA announced several changes in relation to the addition of new codes for the COVID-19 vaccine under development by AstraZeneca and University of Oxford. Codes 91302, 0021A, and 0022A were published on the AMA website and will be effective once they have received Emergency Use Authorization (EUA) from the FDA.

tags  Topic: Code Updates    Topic: COVID-19    Topic: CPT Coding   

HIPAA Penalty Changes

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On January 5, 2021, H.R. 7898 was signed into law by President Trump. This new law modifies the HITECH Act such that when an organization experiences a breach, fines and/or penalties may be reduced if (for at least a year) they have instituted “recognized security practices” as defined within the law.

tags  Specl: All Specialties    Topic: Compliance    Topic: HIPAA   

ICD-10 Code Updates for January 1st

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Be aware that new ICD-10-CM and ICD-10-PCS codes took effect on January 1, 2021. Rarely have ICD-10-CM codes been released in January, but as you may have guessed, these changes are in relation to COVID-19. The information in this article will help your organization understand these changes.

tags  Topic: Code Updates    Topic: COVID-19    Topic: ICD10CM Coding    Topic: ICD10PCS Coding   

CMS Final Rule Changes E/M Reporting Guidelines

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Just when we thought we had figured out Evaluation and Management (E/M) reporting for 2021, CMS released their final rule and now we will need to make some adjustments. While CMS stated that they were adopting the AMA guidelines for E/M office or other outpatient services, they did make a few changes.

tags  Topic: CPT Coding    Topic: E+M Documentation and Coding    Topic: HCPCS Coding    Topic: Modifier Coding    Topic: Procedure Coding   

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