Medical Coding and Billing Articles

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PCS Coding for Ankle Fracture - Look Deeper Into the Codes!

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If you're looking for ankle fractures in ICD-10-PCS, you may need to look a little deeper. Let's take a look at coding an ankle fracture such as a trimalleolar fracture. PCS coding can be confusing as it is nothing like CPT coding; with CPT we can simply code an ankle ...

tags  Specl: Orthopedics    Specl: Primary Care|Family Care    Topic: CPT Coding    Topic: Facilities    Topic: Hospital    Topic: ICD10PCS Coding    Topic: Procedure Coding   

Intersegmental Traction — What’s Happening with Roller Tables?

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Intersegmental traction therapy via the use of roller tables has been used by doctors of chiropractic for many years. Recently, questions have arisen regarding the appropriate billing of roller tables. This is largely due to the statement published in the July 2020 CPT Assistant published by the American Medical Association (AMA). Which code should you really be using?

tags  Specl: Chiropractic    Specl: Physical Medicine|Physical Therapy    Topic: Coding    Topic: Compliance    Topic: CPT Coding    Topic: Procedure Coding   

Congress Has Been Busy — 11 Different Bills Pass Covering Mental Health and Substance Use

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The House of Representatives has certainly been working hard to advance behavioral health services. This article summarizes each of those bills and includes a link to contact your Senator.

tags  Specl: Behavioral Health|Psychiatry|Psychology    Specl: Emergency Medicine    Topic: Coding    Topic: Health Care Reform    Topic: Practice Management    Topic: Substance Use Disorder   

OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment

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As the OIG has published their intent to further investigate the 9.5% of improper payments based on incorrect ICD-10-CM code assignation, they implore Managed Care Organizations (MCOs) to begin employing some of the CMS tools and data analytic programs used to help identify outliers.

tags  Loc: All Locations    Payer: All Payers    Specl: Risk Adjustment|HCC Coding    Topic: Diagnosis Coding    Topic: Documentation    Topic: Fraud    Topic: Guidelines ICD-10-CM    Topic: ICD10CM Coding    Topic: OIG    Topic: Risk Adjustment   

Since When did Dental Claims Require Diagnosis Codes?

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The objective of the Accountable Care organization is to integrate and consolidate patient care management to improve patient outcomes. Changes and coordination of dental and medical care are already becoming more apparent when dental offices are being required to bill a patient's medical plan for dental visits due to an ...

tags  Specl: Dental    Topic: ACO - Accountable Care Organization    Topic: CDT (Dental) Codes    Topic: Claims Processing    Topic: ICD10CM Coding   

Compliance in the Dental Office or Small Practice

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If your practice does not already have a compliance program in place, you will want to get started after reading this article. We have uncovered some important findings with the Office of Inspector General (OIG) in dental practices you need to be aware of. A compliance program offers standard procedures to follow, ...

tags  Specl: All Specialties    Specl: Dental    Topic: Claims Processing    Topic: Compliance   

Identifying Risk-Adjusted Services During the Opioid Crisis

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Between June 2019 and June 2020, the United States saw a total of 107,750 deaths from COVID-19. The spread of this virus was so extraordinary that it led President Trump to declare a public health emergency, and we watched as individual states began implementing laws and regulations to limit social interaction ...

tags  Loc: All Locations    Payer: All Payers    Specl: Behavioral Health|Psychiatry|Psychology    Specl: Pain Management    Specl: Risk Adjustment|HCC Coding    Topic: Risk Adjustment   

Comparison of Add-On Code Guidelines

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Add-on codes are codes that are not intended to be reported alone. They are reported with another primary procedure to identify that additional services have been provided in conjunction with that primary procedure. Generally, they include the words “List separately in addition to code.” Interestingly, there are some differences in the instructions/guidelines regarding the use of these codes in the CPT® codebook, the NCCI Policy Manual, and on the CMS website. This article outlines the differences between each of these.

tags  Specl: Behavioral Health|Psychiatry|Psychology    Specl: Chiropractic    Specl: Obstetrics|Gynecology    Specl: Ophthalmology    Specl: Optometry    Specl: Oral and Maxillofacial Surgery    Specl: Pain Management    Specl: Physical Medicine|Physical Therapy    Topic: CPT Coding    Topic: HCPCS Coding    Topic: Modifier Coding    Topic: Procedure 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: Coding    Topic: CPT Coding    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   

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   

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   

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   

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   

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