2021 ICD-10-CM and ICD-10-PCS CODING HANDBOOK
The handbook's format and style of presentation follows that of previous editions inspired by the Faye Brown approach to coding instruction. The handbook is authored by Nelly Leon-Chisen, RHIA, Director of Coding and Classification at the AHA.
- Fiscal year 2021 code updates, including new information on COVID-19, vaping-related disorder, history of diabetes mellitus or hypertension, immunodeficiency, cytokine release syndrome,cerebrospinal fluid leak, intracranial hypotension, neonatal cerebral infarction, and “chronic stroke”
- Up-to-date guidance on coding signs and symptoms, diseases, disorders, procedures, conditions, complications of care, long-term care, and more
- Reflects the Official Coding Guidelines
- Over 200 chapter-based and final review exercises
- Built-in workbook of case summary exercises
- More than 50 four-color illustrations of anatomy, common disorders, and procedures
"Location: All Locations" & "Billing" Articles
Click on the title to see the article summary and a link to the full article.
April 19th, 2021
Q/A: For E/M, How do I Count Tests Ordered in One Department and Performed in Another?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 19th, 2021
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.
April 12th, 2021
How to Combat COVID-Related Risk Adjustment Losses with the Medicare Annual Wellness Exam
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 12th, 2021
Identifying new ways to encourage Medicare beneficiaries to schedule and attend their Annual Wellness Exam (AWE) can be difficult, but the Open Enrollment period is a prime time for every payer to identify new beneficiaries and provide a reminder to both new and existing patients that this preventive service does ...
April 12th, 2021
Failure to Follow Payer’s Clinical Staff Rules Costs Provider $273K
By Wyn Staheli, Director of Research | Published April 12th, 2021
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.
April 8th, 2021
Properly Reporting Imaging Overreads (Including X-Rays)
By Aimee Wilcox CPMA, CCS-P, CST, MA, MT and Wyn Staheli, Director of Content Research | Published April 8th, 2021
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.
March 18th, 2021
How Reporting E/M Based on Time May Lose Money
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 18th, 2021
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 ...
March 10th, 2021
How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 10th, 2021
The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. Learn how to address this important subject.
February 1st, 2021
New Procedure Codes for the Janssen COVID-19 Vaccine
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 1st, 2021
On January 19, 2021, the AMA announced two new CPT codes for reporting the Janssen Pharmaceutica (a division of Johnson & Johnson) COVID-19 vaccine. Of course, just as with the other COVID-19 vaccines, they must be given FDA approval for Emergency Use Authorization (EUA) to be administered before the codes can be reported.
As is ...
January 21st, 2021
Looking Beyond an Employee's Coding Credentials
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 21st, 2021
In today's ever-changing healthcare environment, it is important that organizations hire coding and reimbursement personnel who enjoy learning. Each year changes are made in how healthcare services are coded and reported from federal and state laws, the code sets themselves, and varying payer policies. During the public health emergency (PHE) ...
January 7th, 2021
CMS Reduces the Exchange User Fee to Support Lower Premiums for the Consumer
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 7th, 2021
It has been no secret that Americans have been complaining about the high cost of health plans since implementation of the Affordable Care Act (ACA). Premiums and deductibles have skyrocketed and in many states are equal to or exceed the cost of their rent or mortgage payments. As such, most ...
December 8th, 2020
Common Medical to Dental Procedures and Where to Find Them
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 8th, 2020
With healthcare integrating and consolidating the delivery of healthcare systems, it only makes sense using medical insurance affords better management of care, dental providers are quickly picking up the slack on dental policies and utilizing healthcare coverage, understanding this affords better care for their patients. There are many common dental procedures that ...
December 8th, 2020
IPPS and DRG's: What it Means
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 8th, 2020
Understanding hospital pricing can get complicated, so we have broken it down according to CMS and the acute Inpatient Prospective Payment System, also known as IPPS. Find-A-Code uses IPPS for inpatient pricing with our MS-DRG grouper. The following information comes from CMS.gov and answers the most common questions regarding DRGs ...
November 24th, 2020
How Might the New 2021 E/M Guideline Changes Impact Risk Adjustment?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published November 24th, 2020
While provider organizations are busy learning the new E/M guideline changes being implemented January 1, 2021, Medicare Advantage Organizations (MAOs) are contemplating how the documentation changes for these services may impact risk adjustment coding. To be clear, the new E/M guidelines only pertain to Office and Other Outpatient E/M Services ...
November 5th, 2020
Are You Aware of the 2021 Star Rating System Updates?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published November 5th, 2020
Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues:
Quality of ...
October 26th, 2020
Delving Into the 360 Assessment Fraud Complaint
By Jessica Hocker, CPC, CPB | Published October 26th, 2020
The Department of Justice is pursuing claims of healthcare fraud against Cigna Health-Spring Medicare Advantage plan based on how they used data from their 360 Program in 2012. A review of the allegations may help other payers avoid similar accusations.
October 12th, 2020
What is the Difference Between the Medicare 1995 and 1997 Documentation Guidelines for E/M Services?
By Aimee Wilcox | Published October 12th, 2020
When Medicare determined that providers could follow EITHER the 1995 OR the 1997 Documentation Guidelines for Evaluation and Management Services to determine which level of E/M service to report, because CMS had not clarified that portions of the 1995 and 1997 guidelines could be used together to determine the level of ...
August 24th, 2020
2021 Brings Another Risk Adjustment Calculation Change
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published August 24th, 2020
In 2021, a big change in Risk Adjustment score calculations will take place, which will affect payments to Medicare Advantage (MA) plans for the coming year and take us closer to quality and value-based programs instead of fee-for-service (FFS) or risk-adjusted (RA). Currently, CMS pays a per-enrollee capitated...
July 15th, 2020
Use the Correct Diagnosis Codes and Revenue Codes to Get Paid for PAD Rehab
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 15th, 2020
The initial treatment in rehabilitation for patients suffering from Intermittent Claudication (IC) is Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD). Rehabilitation using SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest.
When reporting 93668 for peripheral arterial disease rehabilitation the following ...
July 14th, 2020
Are NCCI Edits and Modifiers Just for Medicare?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 14th, 2020
The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that ...
July 9th, 2020
Payment Adjustment Rules for Multiple Procedures and CCI Edits
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2020
Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...
June 29th, 2020
HCPCS Codes Were NOT all Created for the Same Purpose
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 29th, 2020
Have you ever wondered why you were unable to find a particular product/code with our DMEPOS search? When looking for HCPCS Level II codes, there are several kinds of codes and not all HCPCS codes were created for the same purpose. If you are searching for a certain HCPCS product ...
June 15th, 2020
Outpatient Facility Pricing
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 15th, 2020
Our newest feature launch offers UCR pricing for Outpatient Facility. We recently released pricing information based on databases of insurance claims from private-sector health care providers.Usual, customary, and reasonable charges (UCR) are medical fees used when there are no contractual pricing agreements and are used by certain healthcare plans and third-party payers to generate ...
May 18th, 2020
Packaging and Units for Billing Drugs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 18th, 2020
To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number.
Take a look at the following
J1071 - Injection, testosterone cypionate, 1mg
For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL
(100 mg/mL = 1 mL and there are ...
May 13th, 2020
Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 13th, 2020
On April 10th, CMS released a memo with the subject line, “Applicability of diagnoses from telehealth services for risk adjustment,” suggesting there may be some telehealth services that might not qualify for risk adjustment. However, in the memo CMS states:
“Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face ...
May 4th, 2020
Additional Telehealth Changes Announced by CMS
By Wyn Staheli, Director of Research | Published May 4th, 2020
On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.
April 20th, 2020
Dismal OIG Report on Telemedicine
By Wyn Staheli, Director of Research | Published April 20th, 2020
Providers need to understand the rules for reporting telemedicine services. A recent OIG report shows that this is not the case. What problems are being found in documentation claims? As providers are expanding their telehealth offerings, now is the time to understand the potential pitfalls since disallowed amounts will be taken back.
April 15th, 2020
New CPT® Codes Approved for COVID-19 Antibody Identification
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 15th, 2020
On April 10, 2020, the American Medical Association approved and published a revision of code 86318 and added two new codes 86328 and 86769 for reporting Coronavirus [COVID-19] antibody testing.
April 15th, 2020
CMS Temporarily Suspends Contract-Level RADV Audits
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 15th, 2020
The Centers for Medicare and Medicaid Services (CMS) is suspending contract-level RADV audits, related to the payment year 2015 and will not initiate any new ones until after the public health emergency has ended. Any documentation already submitted will be reviewed as usual.
April 13th, 2020
CMS Announces Final 2021 HCC Risk Adjustment Changes
By Wyn Staheli, Director of Research | Published April 13th, 2020
On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) published their final Medicare Advantage (MA) and Part D payment methodologies for CY 2021. Read more to be prepared for these upcoming changes.
March 25th, 2020
COVID-19: Cybercrime, Telehealth, and Coding
By Wyn Staheli, Director of Research | Published March 25th, 2020
Your inbox is probably like mine with all sorts of announcements about COVID-19. Here are just a few reminders of things we felt should be passed along.
We have heard of several cases of cybercrime related to this outbreak. For example, there was a coronavirus map which loads malware onto your ...
March 24th, 2020
"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 24th, 2020
Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...
March 21st, 2020
Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2020
The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...
February 10th, 2020
A 2020 Radiology Coding Change You Need To Know
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 10th, 2020
The radiology section of the 2020 CPT© has 1 new, 18 revised, and 14 deleted codes. Interestingly, six of the 14 deleted codes were specific to reporting single-photon computerized tomographic (SPECT) imaging services of the brain, heart, liver, bladder, and others. If your organization reports radiology services, it is...
January 30th, 2020
Medicare Announces Coverage of Acupuncture Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 30th, 2020
On January 21, 2020, a CMS Newsroom press-release read,
This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for ...
December 23rd, 2019
Time Is Up! Jan 1 2020 Claims Will be Denied Without MBIs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 23rd, 2019
New Medicare Card Transition Ends Next Week: Claim Reject Codes Beginning January 1
If you want to get paid you should be reporting MBIs on all of your Medicare claims. The deadline is here: if you are not using Medicare Beneficiary Identifiers (MBIs) on claims (with a few exceptions) after January 1, ...
December 9th, 2019
Regence: Dental Procedures Under The BlueCard Program?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 9th, 2019
This information can be found on Regence/Blue Cross Dental procedures explaining additional benefits for dental procedures. Regence currently does not offer dental benefits, however, there are times a patient can receive treatment with a Blue Cross provider and qualify under their medical benefits. In addition, Regence informs the providers to file these claims ...
November 19th, 2019
Q/A: How do I Code a Procedure for the Primary Insurance so the Secondary Can Get Billed?
By Wyn Staheli, Director of Research | Published November 19th, 2019
Question: How do you modify a code submitted to the primary insurance company to let them know it is not covered by them so you can bill to a secondary?
October 1st, 2019
Do ICD-10 Updates Have Your Heart Beating Irregularly? Check Out the New Atrial Fibrillation Codes
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 1st, 2019
Atrial fibrillation (AF) is the most common type of abnormal heart rhythm (arrhythmia). It is caused by a disorder in the heart’s electrical system. AF is the result of abnormal contractions of the atria (upper two chambers of the heart) causing them to quiver and beat out of sync with ...
October 1st, 2019
The New ICD-10-CM Code Updates Are Here — Are You Ready?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 1st, 2019
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)
A small revision in the description changed[STEC] to (STEC) for B96.21, B96.22, B96.23. Remember, in the instructional guidelines, ( ) parentheses enclose supplementary words not included in the description (or not) and [ ] brackets enclose synonyms, alternative wording, or explanatory phrases.
Chapter 2: ...
August 20th, 2019
Are You Aware of Medicare Advantage Plans Timely Filing Rules?
By Aimee Wilcox | Published August 20th, 2019
The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial.
As any company who has billed Medicare services can attest, the one-year timely filing ...
August 13th, 2019
How to Properly Report Prolonged Evaluation and Management Services
By Aimee Wilcox | Published August 13th, 2019
Have you ever had a patient take more time with the provider than they were scheduled for? Do you understand which codes to report and the rules that govern them to allow for better reimbursement?
Prolonged Service codes were created just for that reason but you must carefully follow the documentation ...
July 29th, 2019
Q/A: How do I Bill Mobile Clinic Services?
By Evan Gwilliam DC, MBA, BS, CPC, CCPC, CPC-I, QCC, MCS-P, CPMA, CMHP, AAPC Fellow | Published July 29th, 2019
Question: I have a part time mobile clinic. I travel to treat patients at their homes. Are there special considerations when billing for these encounters?
July 17th, 2019
Act Now on CMS Proposal to Cover Acupuncture for Chronic Low Back Pain
By Wyn Staheli, Director of Research | Published July 17th, 2019
Now is the time to comment on a proposal to cover acupuncture for chronic low back pain. This comment period is the part of the HHS response to the opioid crisis. You only have until August 14th to officially comment.
July 9th, 2019
The Importance of Medical Necessity
By Marge McQuade, CMSCS, CHCI, CPOM | Published July 9th, 2019
ICD-10-CM codes represent the first line of defense when it comes to medical necessity. Correctly chosen diagnosis codes support the reason for the visit as well as the level of the E/M services provided. The issue of medical necessity is one of definitions and communication. What is obvious to the ...
July 8th, 2019
Q/A: Can I Put the DC’s NPI in Item Number 24J for Massage Services?
By Wyn Staheli, Director of Research | Published July 8th, 2019
Question:
Are there scenarios in which it is acceptable to put the DC's NPI in box 24j for massage services?
Answer:
While the answer to this is yes, it is essential to understand that there are very limited scenarios. In most cases, Item Number 24J is only for the NPI of the individual ...
June 18th, 2019
How to Properly Report Monitoring Patients Taking Blood-thinning Medications
By Wyn Staheli, Director of Research | Published June 18th, 2019 - Last Review/Update June 19th, 2019
Codes 93792 and 93792, which were added effective January 1, 2019, have specific guidelines that need to be followed. This article provides some guidance and tips on properly reporting these services.
June 17th, 2019
Extrapolation Policies Apply to RAD-V Audits
By Aimee Wilcox | Published June 17th, 2019
Risk Adjustment is a program that was implemented to identify and support Medicare beneficiaries with health conditions, illnesses, or injuries that put them at risk of death or organ system/bodily function failure. Through Risk Adjustment (RA), Medicare ensures their beneficiaries are being followed at least annually for any healthcare conditions ...
June 14th, 2019
A United Approach
By Namas | Published June 14th, 2019 - Last Review/Update June 18th, 2019
A United Approach
As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...
June 13th, 2019
What Medical Necessity Tools Does Find-A-Code Offer?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...
June 6th, 2019
How to Code Ophthalmologic Services Accurately
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 6th, 2019 - Last Review/Update June 11th, 2019
Have you ever tried to quickly recall the elements required to support a comprehensive ophthalmologic exam versus an intermediate one? Make coding decisions quickly by creating a cheat sheet containing vital information that allows you to quickly select the right code.
According to Article A19881 which was published in 2004 and ...
May 29th, 2019
Noting "Noncontributory" for Past Medical, Family, Social History - Is It Acceptable?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 29th, 2019 - Last Review/Update June 4th, 2019
Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?
May 17th, 2019
An Update on the DHS OIG's Effort to Combat Fraud & Abuse
By Namas | Published May 17th, 2019 - Last Review/Update May 21st, 2019
An Update on the DHS OIG's Effort to Combat Fraud & Abuse
Every year, the Department of Health and Human Services (DHS) Office of Inspector General (OIG) is required by law to release a report detailing the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such ...
May 14th, 2019
Spotlight: QPro Blogs
By Brittney Murdock, QCC, CMCS, CPC | Published May 14th, 2019
Look for important tips and updates for the medical industry on the QPro Blog!
The link to the blog is available from the Medical page under the Industries tab.
Use the search bar to look up topics and specialties.
View the blogs page here.
...
May 13th, 2019
Q/A: Two Payers Both Paid the Claim. Who Gets the Refund?
By Wyn Staheli, Director of Research | Published May 13th, 2019
Question
We have a personal injury situation where we submitted a claim was sent to the patient's auto policy carrier who refused payment. We then submitted it to her other insurance. Eventually, both companies paid her claims. Her auto paid at full value, and her secondary paid at a reduced rate ...
May 13th, 2019
Prioritize Your Patient's Financial Experience
By Wyn Staheli, Director of Research | Published May 13th, 2019
For many years, the ChiroCode DeskBook has emphasized the need for providers to firmly establish the patient’s financial responsibility through clear communication. We even created a “Patient Financial Responsibility Acknowledgment Form” to help providers with this process. Lately, the lack of pricing transparency has been in the news and even ...
May 13th, 2019
Electrical Stimulation and Electromagnetic Therapy Devices
By Raquel Shumway | Published May 13th, 2019 - Last Review/Update May 20th, 2019
Electrical Stimulation and Electromagnetic Therapy Devices can be used for pain, muscle atrophy, help spinal cord injuries, treat symptoms caused by other medical conditions and can be used in the treatment of wounds. This Regence BC/BS article lists codes and devices and gives guidance on coding from Medicare Advantage viewpoint.
April 29th, 2019
Medicare Revises Their Appeals Process
By Wyn Staheli, Director of Research | Published April 29th, 2019
On April 12, 2019, Medicare announced that there will be some changes to their appeals process effective June 13, 2019. According to the MLN Matters release (see References), the following policy revisions in the Medicare Claims Processing Manual (MCPM), Chapter 29 are taking place:
The policy on use of electronic signatures
Timing ...
April 23rd, 2019
Let's Talk High Risk E/M Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.
Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...
April 23rd, 2019
What is Medical Necessity and How Does Documentation Support It?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
We recently fielded the question, “What is medical necessity and how do I know if it's been met?"
The AMA defines medical necessity as:
It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
April 22nd, 2019
Auditing Chiropractic Services
By By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow Clinical Director, PayDC Chiropractic EHR Software President, Gwilliam Consulting LLC drgwil@gmail.com | Published April 22nd, 2019
Chiropractic is unique from other types of health care and auditors need to be aware of the nuances of this field. Chiropractic has become the focus of more and more audits as doctors seem to struggle to create records that properly support the care provided to the patient throughout the entire episode.
April 22nd, 2019
Q/A: What’s Wrong with the Diagnoses on my Claim?
By Wyn Staheli, Director of Content | Published April 22nd, 2019
Question: I got a denial on my claim and it said the problem was with the diagnoses codes that I used. I used M54.15 and M79.2. I don’t understand why this is a problem.
April 15th, 2019
Q/A: How Many Diagnosis Codes do I use?
By Wyn Staheli, Director of Research | Published April 15th, 2019
Question: My patient has a lot of chronic conditions. Do I need to include all these on the claim? I know that I can have up to 12 diagnoses codes on a single claim. What if I need more than that?
Answer: More is not always better. You only need to ...
April 8th, 2019
Prepayment Review Battle Plan
By Wyn Staheli, Director of Research | Published April 8th, 2019
Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...
March 29th, 2019
Prolonged Services
By Namas | Published March 29th, 2019 - Last Review/Update April 4th, 2019
Prolonged Services
I find in my own audit reviews that the prolonged service code set is often mistreated: they are avoided and not used even when the scenario supports them, or they get overused and improperly documented. Prolonged services are used in conjunction with all types of Evaluation and Management (E/M) ...
March 26th, 2019
Add on Codes for CPT (Appendix D)
By Find-A-Code | Published March 26th, 2019 - Last Review/Update April 2nd, 2019
For 2019, the following is a list of CPT add-on codes:
01953
19294
33225
37223
61864
76814
93325
97598
01968
19297
33257
37232
61868
76937
93352
97811
01969
20930
33258
37233
62148
76979
93462
97814
10004
20931
33259
37234
62160
76983
93463
99100
10006
20932
33367
37235
63035
77001
93464
99116
10008
20933
33368
37237
63043
77002
93563
99135
10010
20934
33369
37239
63044
77003
93564
99140
10012
20936
33419
37247
63048
77063
93565
99153
10036
20937
33508
37249
63057
77293
93566
99157
11001
20938
33517
37252
63066
78020
93567
99292
11008
20939
33518
37253
63076
78496
93568
99354
11045
20985
33519
38102
63078
78730
93571
99355
11046
22103
33521
38746
63082
81266
93572
99356
11047
22116
33522
38747
63086
81416
93592
99357
11103
22208
33523
38900
63088
81426
93609
99359
11105
22216
33530
43273
63091
81536
93613
99415
11107
22226
33572
43283
63103
82952
93621
99416
11201
22328
33768
43338
63295
86826
93622
99467
11732
22512
33866
43635
63308
87187
93623
99486
11922
22515
33884
44015
63621
87503
93655
99489
13102
22527
33924
44121
64462
87904
93657
99494
13122
22534
33929
44128
64480
88155
93662
99498
13133
22552
33987
44139
64484
88177
94645
99602
13153
22585
34709
44203
64491
88185
94729
99607
14302
22614
34711
44213
64492
88311
94781
0054T
15003
22632
34713
44701
64494
88314
95079
0055T
15005
22634
34714
44955
64495
88332
95873
0076T
15101
22840
34715
47001
64634
88334
95874
0095T
15111
22841
34716
47542
64636
88341
95885
0098T
15116
22842
34808
47543
64643
88350
95886
0163T
15121
22843
34812
47544
64645
88364
95887
0164T
15131
22844
34813
47550
64727
88369
95940
0165T
15136
22845
34820
48400
64778
88373
95941
0174T
15151
22846
34833
49326
64783
88388
95962
01953
15152
22847
34834
49327
64787
90461
95967
01968
15156
22848
35306
49412
64832
90472
95984
01969
15157
22853
35390
49435
64837
90474
96113
0205T
15201
22854
35400
49568
64859
90785
96121
0214T
15221
22858
35500
49905
64872
90833
96131
0215T
15241
22859
35572
50606
64874
90836
96133
0217T
15261
22868
35600
50705
64876
90838
96137
0218T
15272
22870
35681
50706
64901
90840
96139
0222T
15274
26125
35682
51797
64902
90863
96160
0229T
15276
26861
35683
52442
64913
91013
96161
0231T
15278
26863
35685
56606
65757
92547
96361
0290T
15777
27358
35686
57267
66990
92608
96366
0376T
15787
27692
35697
58110
67225
92618
96367
0396T
15847
29826
35700
58611
67320
92621
96368
0397T
16036
31627
36218
59525
67331
92627
96370
0399T
17003
31632
36227
60512
67332
92921
96371
0437T
17312
31633
36228
61316
67334
92925
96375
0439T
17314
31637
36248
61517
67335
92929
96376
0443T
17315
31649
36474
61611
67340
92934
96411
0450T
19001
31651
36476
61641
69990
92938
96415
0466T
19082
31654
36479
61642
74301
92944
96417
0471T
19084
32501
36483
61651
74713
92973
96423
0480T
19086
32506
36907
61781
75565
92974
96570
0482T
19126
32507
36908
61782
75774
92978
96571
0492T
19282
32667
36909
61783
76125
92979
96934
0496T
19284
32668
37185
61797
76802
92998
96935
0513T
19286
32674
37186
61799
76810
93320
96936
0514T
19288
33141
37222
61800
76812
93321
97546
0523T
...
March 22nd, 2019
Q/A: How do we Know Which Codes a Payer Will Allow?
By Wyn Staheli, Director of Research | Published March 22nd, 2019
How do we know which codes a payer will allow?
The best way to determine the codes (CPT, ICD-10-CM and HCPCS) allowed by a payer is to review their payer policy. While it is good to know the official guidelines (e.g., ICD-10-CM Official Guidelines for Coding and Reporting, AMA Guidelines, Medicare ...
March 21st, 2019
The Impact of Medical Necessity on High Level E/M Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2019
I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?"
The quick answer is, "it depends."
Code 99233 has the following minimal component requirement:
Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...
March 18th, 2019
How to Report Imaging (X-Rays) of the Thumb
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 18th, 2019
If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all ...
March 7th, 2019
Q/A: Can you Help me Understand the New Medicare Insurance Cards?
By Wyn Staheli, Director of Research | Published March 7th, 2019
As many of you are aware, CMS began issuing new Medicare identification cards last year which required the replacement of social security numbers with a new Medicare Beneficiary Identifier (MBI). All cards have now been mailed out and patient's should have the new cards when they come in. Currently, we are in the transition period until January 2020.
March 4th, 2019
UnitedHealthcare to Discontinue Coverage of Consultations
By Wyn Staheli, Director of Research | Published March 4th, 2019 - Last Review/Update March 7th, 2019
In United Healthcare's March provider bulletin, they announced that beginning on June 1, 2019, they will be phasing out coverage of consultation services (99241-99255).
March 1st, 2019
Understanding NCCI Edits
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 1st, 2019
Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...
February 25th, 2019
Medicare Supplemental Policies (MediGap) and Extremity Adjustments
By Wyn Staheli, Director of Research | Published February 25th, 2019
The nice thing about MediGap policies is that they pay for some of the healthcare costs that an original Medicare plan (Part B) does not cover. So when a patient has Medicare and a Medicare supplement (MediGap) and their condition is related to an extremity (a noncovered service), Medicare must ...
February 22nd, 2019
Q/A: What's the Difference Between Q5 and Q6 for a Substitute Provider?
By Wyn Staheli, Director of Research | Published February 22nd, 2019 - Last Review/Update March 5th, 2019
It is important to understand that modifiers Q5 and Q6 are not interchangeable. So when do you use each of them?
February 19th, 2019
Consent for CT Scan - Women
By Christine Taxin | Published February 19th, 2019
The ADA has forms in over 26 lanuages available to purchase. You also need specific forms for all of the procedures. Even working with patients who are pregnant needs to have a consent with a specialty and collaboration with medical providers. I am showing you one of the forms...
February 14th, 2019
Proposed Rule: Expanded Telemedicine Benefits for Medicare Advantage Beneficiaries
By Aimee Wilcox | Published February 14th, 2019
Telemedicine continues its rise, with new technologies allowing for better communication and access to more aspects of healthcare than ever before. Each year Medicare has made strides, albeit small strides, in their telemedicine coverage while commercial payers continue to make great strides, constantly improving and expanding telemedicine service offerings to ...
February 12th, 2019
Coding Medicare Initial Preventive Physical Exams (IPPE)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 12th, 2019
The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward.
Purpose
An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...
January 23rd, 2019
QPro - Medical Certifications
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 23rd, 2019
QPro (Qualified Professionals) is a member support system dedicated to enhancing coding and management through certification for healthcare coders and managers. Through increased knowledge of coding principles, changes in coding policies, and the experiences of fellow coders and managers in resolving office challenges, QPro members confidently code for maximum and ...
January 23rd, 2019
How to Report Co-Surgeons Using Modifier 62
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2019
Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session.
An easy way to explain this is to visualize a patient requiring cervical fusion where ...
January 4th, 2019
Nine New Codes for Fine Needle Aspirations (FNA) in 2019
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 4th, 2019
If your practice performs a lot of fine needle aspirations (FNA), you probably have the code options memorized (10021 without image guidance and 10022 with image guidance). However, the 2019 CPT codes now include nine (9) new FNA codes (10004-10012), one deleted FNA code (10022) and one revised FNA code ...
January 3rd, 2019
New Genetic Test for Severe Inherited Conditions
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 3rd, 2019
For 2019 a new code has been introduced (81443) which represents genetic testing for 15 genes associated with severe, inherited conditions. The results of this test may be used to identify carrier status during prenatal genetic counseling, confirm a clinical diagnosis, or identify at-risk family members for the following severe ...
November 29th, 2018
Errors Billing Outpatient Services When Patient is also Inpatient
By Wyn Staheli, Director of Research | Published November 29th, 2018
The OIG recently reported that Medicare inappropriately paid acute-care hospitals for outpatient services provided to patients who were inpatients of another facility including long term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and critical access hospitals. CMS suggests using the following resources to ensure compliance:
Medicare Inappropriately Paid Acute-Care Hospitals for ...
November 28th, 2018
No Good Deed Goes Unpunished
By Dr. Ray Foxworth, MCS-P, President of ChiroHealthUSA | Published November 28th, 2018 - Last Review/Update January 21st, 2019
You simply need to read the headlines, posts, and tweets, about providers across the healthcare profession being audited, fined, and some even convicted, to see that the costs of non-compliance are real. We tell ourselves, “It won’t happen to me.” The reality is that it easily could. Your license is your livelihood.
November 26th, 2018
Reciprocal Billing and Locum Tenens Arrangements Changes
By Wyn Staheli, Director of Research | Published November 26th, 2018
CMS has made changes to their payment policies for reciprocal billing arrangements and Fee-For-Time compensation arrangements (formerly referred to as locum tenens arrangements). Providers need to be aware of these changes and update their policies as appropriate.
November 7th, 2018
Q/A: What do I do When my State Doesn't Require Pre-certifications for PI, but the Payer in Another State Does?
By Wyn Staheli, Director of Research | Published November 7th, 2018 - Last Review/Update December 19th, 2018
Question:
In Pennsylvania for Personal Injury cases we do not need to go through specific care paths or get precertification in order to treat patients, however, in New Jersey (NJ), doctors that practice there are required to get that precertification. Our question is that when we bill a New Jersey auto ...
October 22nd, 2018
Q/A: Does My LMT need an NPI? How do I Bill Her Services?
By Wyn Staheli, Director of Research | Published October 22nd, 2018 - Last Review/Update December 19th, 2018
Question:
I am setting up an LMT to work as employee under Dr. Clifton, DC. i need to know several things - hoping they are related and can be grouped into this one question.... does she need her own NPI? where does that NPI # go? what box #? if not, ...
October 11th, 2018
Type of Bill Codes
By Find-A-Code | Published October 11th, 2018
Type of bill codes identifies the type of bill being submitted to a payer. Type of bill codes are four-digit alphanumeric codes that specify different pieces of information on claim form UB-04 or form CMS-1450 and is reported in box 4 on line 1.
First Digit = Leading zero. Ignored by CMSSecond ...
September 24th, 2018
Q/A: Do I Have to Accept Any New Patient?
By Wyn Staheli, Director of Research | Published September 24th, 2018 - Last Review/Update January 28th, 2019
Question: Is it legal for us to not allow a patient to be seen in our office if their parents have bad debt with us?
September 12th, 2018
Join QPro Today and Get Certified
By Find a Code | Published September 12th, 2018
Join QPro Today and Get Certified!
To have a credential in the medical profession shows you have met a minimum standard for professional and ethical standards.
Often employers prefer to hire staff that will be involved with any type of patient information such as coding, to show proof they have met certain ...
August 16th, 2018
Medicare Timed Codes Guidelines
By Wyn Staheli, Director of Research | Published August 16th, 2018
Medicare's guidelines for reporting of timed codes is found in Medicare Claims Processing Manual Chapter 5, Section 20.2. Also known as the '8 minute' rule, it describes how to calculate time for appropriate reporting when more than one timed code is performed at the same time.
It should be noted that while ...
August 16th, 2018
Using Modifiers 96 and 97
By Wyn Staheli, Director of Research | Published August 16th, 2018
The Affordable Care Act (ACA) requires coverage of certain essential health benefits (EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. ...
August 16th, 2018
Q/A: Can I Bill Mechanical Massage?
By Wyn Staheli, Director of Research | Published August 16th, 2018 - Last Review/Update January 30th, 2019
Are there any alternative procedure codes for billing mechanical massage (e.g., muscle master vibromassage, genie rub, etc)? I know that 'by the book' mechanical devices are not covered under 97124, but wondered if you have suggested a go-around code.
August 13th, 2018
Using Modifiers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 13th, 2018
Modifiers offer supplemental information and provide additional details without changing the procedure codes definition and are always two digits. Modifiers are required for proper billing and at times used with NCCI edits, however, two or more NCCI -associated modifiers on the same line will be denied. In addition, NCCI modifiers ...
July 25th, 2018
Q/A: Can I Bill Spinal Decompression Table to Insurance?
By Wyn Staheli, Director of Research | Published July 25th, 2018 - Last Review/Update January 28th, 2019
Are visits when a Chiropractor just uses a spinal decompression table billable to insurance? If so, what code is recommended?
July 12th, 2018
Q/A: Can You Swap Out 97140 with 97530?
By Wyn Staheli, Director of Research | Published July 12th, 2018 - Last Review/Update January 28th, 2019
Codes 97140 and 97530 are not interchangeable. See why.
June 26th, 2018
WHO Said ICD-11 is Coming Soon
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 26th, 2018
Sooner or later ICD-11 will be released, and it sounds like it will be sooner than later. WHO released the news on June 18, 2018. The World Health Organization stated “ICD-11 will be presented at the World Health Assembly in May 2019 for adoption by Member States, and will come ...
June 14th, 2018
Home Oxygen Therapy -- CMN for Oxygen
By Raquel Shumway | Published June 14th, 2018
The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.
June 7th, 2018
Three Ways Bundled Payments Can Be a Success
By BC Advantage | Published June 7th, 2018 - Last Review/Update July 3rd, 2018
Bundled payment models continue to attract interest for their potential benefits over traditional fee-for-service payment models. With bundled payments, also known as episode-based payments or packaged pricing, a group of providers is reimbursed based on a contracted price to cover all of the care and services related to a particular ...
May 30th, 2018
Routine Waiver of Patient Out of Pocket Expenses
By Linda Walker | Published May 30th, 2018 - Last Review/Update June 4th, 2018
Medical billers often encounter the dilemma of a physician who wants to be the hero to his or her patients and waive their out-of-pocket expenses. Out-of-pocket expenses include a patient's co-payment, coinsurance, deductibles, charges above U&C (Usual and Customary), and even services a plan may not cover in some situations....
May 14th, 2018
TKAs to Outpatient What We Have Learned with Q1
By Shannon Cameron, MBA, MHIIM, CPC | Published May 14th, 2018 - Last Review/Update May 24th, 2018
The release of the 2018 Final Rule for the Outpatient Prospective Payment System (OPPS) in November 2017 has created quite a stir across the orthopedic healthcare community. In what has been deemed a questionable decision, the Centers for Medicare and Medicaid Services (CMS) decided to remove Total Knee Arthroplasty...
May 7th, 2018
Q/A: How Do I Respond to a Patient's Request to Not Submit the Claim to Their Insurance?
By Wyn Staheli, Director of Research | Published May 7th, 2018 - Last Review/Update January 30th, 2019
A number of patients now have high deductible plans. Sometimes, deductibles can be $5000 or $10,000. My payer contract states that I must submit all claims to insurance for covered services. However, sometimes patients with these high deductibles come to my office and state that they would prefer to receive a modest discount for paying cash and in turn, not have their services submitted to insurance. As a doctor, this places me in a tough situation. Do I follow the patient's wishes or the payer contract?
May 7th, 2018
Q/A: What Code do I Use for Supraspinatus and Infraspinatus Tendonitis?
By Wyn Staheli, Director of Research | Published May 7th, 2018 - Last Review/Update January 28th, 2019
Is there a better code for supraspinatus and infraspinatus tendonitis than the one for a rotator cuff tear?
April 30th, 2018
Medical to Dental Billing, Truth or Dare?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 30th, 2018
Is it true that medical benefits are only accessible by physicians? This is NOT True! Perhaps you have been told it is illegal for a dentist to bill a patient’s medical insurance, this is erroneous information. In fact, the Accountable Care Organization’s objective is to provide better management of care ...
April 19th, 2018
Proper Record Keeping and Documentation
By | Published April 19th, 2018
Proper record keeping and documentation is not only essential for today’s dental practitioner, but is also required by law. Moreover, correct, current and accurate records directly enhance patient care by enabling the dentist to plan treatments, monitor progress, and provide essential notations. Clear and concise treatment plans, medical alerts, and ...
April 12th, 2018
Dentists Submitting Claims to Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 12th, 2018
When a Dental provider is treating a Medicare Beneficiary, it is important to get a copy of the Medicare card to verify the patient's medical benefits, provider eligibility and claims address/submission prior to submitting a claim. CMS is in the process of changing Medicare Policy Numbers, so you may see ...
April 4th, 2018
What Do Patients Expect in 2018?
By BC Advantage | Published April 4th, 2018 - Last Review/Update April 12th, 2018
Evolutions in technology continue to merge with a trend toward consumerism in healthcare. As a result, patients are expecting a different kind of experience in managing their healthcare....
March 29th, 2018
Medicare Telemedicine Changes for 2018
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 29th, 2018
Find-A-Code presented a webinar on “Coding and Auditing Telemedicine Services,” on March 29, 2018, which did not include the new and updated CMS information published in the MNL Matters Number: MM10393 on January 2, 2018. New and exciting changes were introduced in this article, which is addressed below.
Originating Site Fee
Each ...
March 27th, 2018
Home Oxygen Therapy -- A Face-to-Face Encounter
By Raquel Shumway | Published March 27th, 2018 - Last Review/Update June 14th, 2018
What is required for a Home Oxygen Therapy, Face-to-Face Encounter.
March 26th, 2018
Avoiding D9 Denials
By Nicole, QCC | Published March 26th, 2018
The following is according to WPS.
Please make sure what is bold below is entered verbatim on the second line of the "Remarks" section. This should be the only thing on the second line of remarks:
Patient control nbr - If you are changing or adding a patient control number
Admission hour - If you are changing or adding the admission ...
March 6th, 2018
Increase Revenue by Outsourcing Medical Billing
By iSALUS Healthcare's | Published March 6th, 2018 - Last Review/Update April 12th, 2018
Many practices are starting to weigh the benefits outsourcing medical billing compared to keeping it in-house....
February 28th, 2018
Telemedicine Billing and Reimbursement
By Jared Staheli | Published February 28th, 2018
The opportunities for providers who want to provide telemedicine continue to expand in all sectors of the healthcare market. Even the VA, long a symbol of a fossilized, bureaucratic healthcare entity, has begun to embrace this technology. Though most are familiar with what telemedicine is, many still have questions surrounding ...
February 23rd, 2018
The Comprehensive Error Rate Testing Program
By Frank Cohen, MBA, MPA | Published February 23rd, 2018 - Last Review/Update February 26th, 2018
With nearly a million physicians in this country, how do auditing organizations determine whom to audit?
February 1st, 2018
Don’t Be Hesitant About Collecting Co-Pays
By | Published February 1st, 2018
If you are hesitant about collecting co-pays, consider that you may be paying interest on credit cards, property mortgages, and business loans. Each dollar that you do not collect in co-pays could have been used to pay down the practice debt. Without question, if you are having difficulty finding ways ...
February 1st, 2018
Reporting Tooth Numbers and Oral Cavity Areas
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 1st, 2018
When billing for dental procedures you need to identify the exact tooth and/or location in the oral cavity. Qualifiers are used to report the location and tooth number. When billing procedures on teeth and the oral cavity, the JP qualifier is used to identify the tooth number(s) and the JO ...
February 1st, 2018
Traumatic Subluxation Coding Controversy
By Wyn Staheli, Director of Research | Published February 1st, 2018
There has been some controversy over the use of the ICD-10-CM subluxation codes commonly referred to as traumatic (S13.1-, S23.1-, and S33.1-). Are they appropriate for chiropractors to use? The answer to that question is complicated. The problem basically lies in the lack of official guidance and differing opinions on ...
January 24th, 2018
Better Office Communication Leads to Stronger RCM
By Ashley Choate | Published January 24th, 2018 - Last Review/Update March 29th, 2018
According to a recent Physicians Practice study, one of the top five reasons for denied medical claims is a lack of adequate documentation. While this might seem like an electronic records issue, the problem may be bigger than that. ...
January 23rd, 2018
NEW on Find-A-Code...National Coverage Determinations (NCDs)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2018 - Last Review/Update January 25th, 2018
Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...
January 18th, 2018
What's the definition of an Office Visit and Can I Bill it With a Chiropractic Treatment?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published January 18th, 2018 - Last Review/Update February 4th, 2019
What is the definition of Office Visit? Can It be billed with a Chiropractic Treatment? What about using code 99123 E&M code for office visits? Can we bill of office visits even though we are giving chiropractic care?
January 16th, 2018
Patient Relationship Codes
By Wyn Staheli, Director of Research | Published January 16th, 2018
Section 1848(r)(4) of MACRA requires that claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, include codes for the following:
care episode groups
patient condition groups
patient relationship categories
Previously, CMS decided to use procedure code modifiers to report patient relationship codes on Medicare ...
January 15th, 2018
Medicare Requiring Specific Modifiers on Therapy Services
By Wyn Staheli, Director of Research | Published January 15th, 2018
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following:
Services furnished under the Outpatient ...
January 11th, 2018
Preventative Services: Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
By Find-A-Code | Published January 11th, 2018
The following information from the Medicare Learning Network provides guidance on Ultrasound Screening for Abdominal Aortic Aneurysm (AAA)
January 4th, 2018
Special Skilled Nursing Facility (SNF) Billing Exceptions for Laboratory Tests PUB-100 40.4
By Find-A-Code | Published January 4th, 2018
When a SNF furnishes laboratory services directly, it must have a Clinical Laboratory Improvement Act (CLIA) number or a CLIA certificate of waiver, and the laboratory itself must be in the portion of the facility so certified. Normally the A/B MAC (A) makes payment under Part B for clinical laboratory ...
January 4th, 2018
Rural Health Clinic (RHC) Billing PUB-100 40.5
By Find-A-Code | Published January 4th, 2018
For independent RHCs, laboratory services provided in the RHC’s laboratory are not included in the all-inclusive rate payment to the RHC and may be billed separately to the A/B MAC (B). This includes the six basic laboratory tests required for certification as well as any other laboratory tests provided in ...
January 4th, 2018
Skilled Therapy, When it's Appropriate and Billable
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators,
"A service is not considered a skilled therapy service merely because it is furnished by a therapist or by a therapist/therapy assistant under the direct or general supervision, as applicable, of a therapist. If a service can be self-administered or safely and effectively furnished by an unskilled person, ...
January 4th, 2018
Initial Evaluation Codes for PT's and OT's
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators, for initial evaluations, PTs shall use code 97161-97163 and OTs shall use code 97164-97167. Physicians and other qualified non-physician providers should use the evaluation and management codes 99201-99350 for evaluations.Consider the following points when billing for an evaluation.
These evaluation codes are untimed, billable as one unit.
Do ...
January 4th, 2018
PT and OT Reevaluation Coding
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators, the reevaluation is focused on evaluation of progress toward current goals and making a professional judgment about continued care, modifying goals and/or treatment, or terminating services. Reevaluation provides additional objective information not included in other documentation, such as treatment or progress notes.Reevaluations are distinct from therapy ...
January 4th, 2018
General Physical Therapy Modality Guidelines
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators, CPT codes 97012, 97016, 97018, 97022, 97024, 97026, and 97028 require supervision by the qualified professional/auxiliary personnel of the patient during the intervention.
CPT codes 97032, 97033, 97034, 97035, 97036, and 97039 require direct (one-on-one) contact with the patient by the provider (constant attendance). Coverage for these codes ...
January 4th, 2018
Diathermy eg Microwave Use and Documentation
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators, the objective of these treatments is to cause vasodilation and relieve pain from muscle spasm. Because heating is accomplished without physical contact between the modality and the skin, it can be used even if skin is abraded, as long as there is no significant edema.Diathermy achieves ...
January 4th, 2018
Ultrasound Therapy
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators, therapeutic ultrasound is a deep heating modality that produces a sound wave of 0.8 to
3.0 MHz. In the human body ultrasound has several pronounced effects on biologic tissues. It is attenuated by certain tissues and reflected by bone. Thus, tissues lying immediately next to bone may receive ...
January 4th, 2018
Hydrotherapy Guidelines
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators, hydrotherapy involves the patient’s immersion in a tank of agitated water in order to relieve muscle spasm, improve circulation, or cleanse wounds, ulcers, or exfoliative skin conditions.Qualified professional/auxiliary personnel one-on-one supervision of the patient is required. If the level of care does not require the skills of ...
January 4th, 2018
Physical Therapist can now bill for a substitute Physical Therapist
By Find-A-Code | Published January 4th, 2018
As of 6/13/2017 Medicare contractors shall accept claims from Physical Therapists, Provider Specialty 65 – Physical Therapist in Private Practice, for services provided by a substitute physical therapist under a fee-for-time compensation arrangement when submitted with the Q6 modifier.
The A/B MAC Part B may pay the patient’s regular physician for physicians' ...
January 4th, 2018
Mechanical Traction Therapy
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators, traction is generally limited to the cervical or lumbar spine with the expectation of relieving pain in or originating from those areas.Specific indications for the use of mechanical traction include cervical and/or lumbar radiculopathy and back disorders such as disc herniation, lumbago, and sciatica.This modality is typically used in conjunction with ...
December 28th, 2017
Anesthesia
By Raquel Shumway | Published December 28th, 2017
Anesthesia services fall into one of the following categories ranging from lowest to greatest:
Local or topical anesthesia (not covered here)
Moderate (conscious) sedation (See “Moderate Sedation” on page xx)
Regional anesthesia
General anesthesia
Anesthesia is the administration of a drug or gas to induce partial or complete loss of consciousness. General anesthesia may only ...
December 20th, 2017
Lung Cancer Screening Counseling and Shared Decision Making Visit, and Annual Screening for Lung Cancer with LDCT
By Find-A-Code | Published December 20th, 2017
Effective February 5, 2015, a CMS National Coverage Determination (NCD) added lung cancer screening counseling and shared decision making visit, and for certain beneficiaries, annual screening for lung cancer with Low Dose Computed Tomography (LDCT), as an additional screening service benefit under the Medicare program if all eligibility criteria described ...
December 18th, 2017
Accreditation and Billing for Office Based Surgery (OBS)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 18th, 2017
The traditional healthcare has seen many changes over the years, one of the newest changes we are seeing is procedures once being done as an inpatient, then as an outpatient and now from the outpatient facility to Office-Based procedures. For an Office or Provider to be eligible to perform Office-Based Surgery the ...
December 12th, 2017
Is Your Practice Making Costly Mistakes with The Billing?
By Marge McQuade CMSCS, CHCI, CPOM | Published December 12th, 2017
You may think your billing processes are working perfectly, but even the best billing process can take more time than it should to collect and some collections are lost altogether. It could be the staff's fault or yours as the office manager, but either way it's a major problem. It's...
December 12th, 2017
Developing Billing & Coding Policies
By Marge McQuade CMSCS, CHCI, CPOM | Published December 12th, 2017
The financial health of every medical practice rests upon correctly coded claims. This is true from not only a financial standpoint since coding drives reimbursement, but from a compliance perspective as well. All of the resources available for coding information and guidance are meaningless without the practice manager sifting through...
November 17th, 2017
Average Wholesale Price (AWP)
By David Berky | Published November 17th, 2017
Clinical Drug Information, LLC Average Wholesale Price (AWP) is intended only to be used by Clinical Drug Information, LLC customers. While many use this information as a price index, the Clinical Drug Information, LLC AWP does not represent an average of wholesale prices from any group of transactions in the ...
November 8th, 2017
Q/A: Physical Exam for Military (Specifically Feet)
By Codepedia | Published November 8th, 2017 - Last Review/Update November 21st, 2017
Q: We had a patient come to our podiatry clinic to get a physical for her feet to qualify for ROTC activities. They came back clear of any deformities, defects, etc. Our scribes listed this visit diagnosis as Z00.00 (Encounter for general adult medical examination without abnormal findings) which seems correct ...
October 31st, 2017
Correct Coding for Group Therapy
By David Klein CPC, CPMA, CHC | Published October 31st, 2017 - Last Review/Update February 5th, 2019
Recent events regarding delegation of services to ancillary personnel have given rise to concerns regarding the delivery of outpatient physical medicine by Chiropractors, specifically regarding the appropriate use of one-on-one codes as opposed to group therapy code CPT 97150 - Therapeutic procedure(s), group (2 or more individuals). This advisory provides guidance on how to properly use one-on-one and group therapy codes, both independently and together.
October 26th, 2017
CMS Proposes to Revise Evaluation & Management Guidelines!!
By BC Advantage | Published October 26th, 2017
According to the recently released 2018 Physician Fee Schedule Proposed Rule, published in the Federal Register, dated July 21, 2017, the Centers for Medicare & Medicaid Services (CMS) acknowledges that the current Evaluation and Management (E/M) documentation guidelines create an administrative burden and increased audit risk for providers. In response, ...
October 18th, 2017
Physicians Reciprocal Billing Arrangements
October 13th, 2017
So, How Do You Decide if a Service was Provided?
By David Glaser, JD | Published October 13th, 2017 - Last Review/Update January 31st, 2018
An earlier coding tip explained that the oft-repeated "if it isn't written, it wasn't done" is good risk management advice, but not a legal truism.....
September 14th, 2017
Double Dipping in the History of the Evaluation and Management Note
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published September 14th, 2017
There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history.
The subcomponents of history include:
Chief Complaint ...
September 12th, 2017
Auditing Prolonged Evaluation and Management Services
By Aimee Wilcox | Published September 12th, 2017 - Last Review/Update September 18th, 2017
At times, there are patients who require prolonged face-to-face time with the provider to discuss or be counseled about their condition, plan of care, risks, complications, alternative therapies, or other medical issues. When E/M services go wild, taking significantly longer than the typical time associated with it, that direct face-to-face ...
September 11th, 2017
Dental Providers- So what are ICD 10 codes?
By Christine Taxin | Published September 11th, 2017
What has been your definition so far when asked about how they are different? What does an ICD-10 code look like? How does an ICD-10 code work?
Have you seen commercials about medical coding schools and wonder if the profession is right for you? With the field expected to grow faster ...
September 8th, 2017
Global Surgical Package: When to Bill and When Not to Bill, that is the Question
By Stephanie Allard, CPC, CEMA, RHIT | Published September 8th, 2017 - Last Review/Update January 31st, 2018
The global surgical package is inclusive of the services that would normally be provided to the patient following surgery. Depending on the global period assigned to a CPT code, the pre-operative, intra-operative and post-operative services could be included in the global surgical package.....
September 1st, 2017
Evaluation and Management
By ChiroCode | Published September 1st, 2017 - Last Review/Update January 31st, 2019
Question
In our office when the doctor initially sees a new patient, we bill a new patient code. (99201, 99202, 99203, or 99204) At that time, the doctor gives the patient an X-ray script and informs them to return to the office with their disk for an ROF (review of findings) to go over their results and also to determine their treatment plan, etc. When this happens, can a separate E/M code be billed, like 99211, 99212, 99213, 99214 or is there another code that can be used?
September 1st, 2017
Preventive Services: Alcohol Misuse Screening and Counseling
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 5th, 2018
The following information from the Medicare Learning Network (MLN) provides guidance on Alcohol Misuse Screening and Counseling.......
September 1st, 2017
Preventive Services: Annual Wellness Visit (AWV)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update March 12th, 2018
The following information from the Medicare Learning Network provides guidance on Annual Wellness Visits (AWV)
September 1st, 2017
Preventive Services: Bone Mass Measurements
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Bone Mass Measurements
September 1st, 2017
Preventive Services: Cardiovascular Disease Screening Tests
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance from the Department of Health and Human Services on Cardiovascular Disease Screening Tests:
80061 -
Lipid panel, this panel must include the following:
82465 - Cholesterol, serum, total
83718 - Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol)
84478 - Triglycerides
Z13.6
All Medicare beneficiaries without apparent signs or symptoms ...
September 1st, 2017
Preventive Services: Counseling to Prevent Tobacco Use
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Counseling to Prevent Tobacco Use....
September 1st, 2017
Preventive Services: Depression Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Depression Screening....
September 1st, 2017
Preventive Services: Diabetes Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Diabetes Screening.....
September 1st, 2017
Preventive Services: Diabetes Self-Management Training (DSMT)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 4th, 2018
The following information from the Medicare Learning Network provides guidance on Diabetes Self-Management Training....
September 1st, 2017
Preventive Services: Glaucoma Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 9th, 2018
The following information from the Medicare Learning Network provides guidance on Glaucoma Screening....
September 1st, 2017
Preventive Services: Hepatitis B Virus (HBV) Vaccine and Administration
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 9th, 2018
The following information from the Medicare Learning Network provides guidance on Hepatitis B Virus (HBV) Vaccine and Administration....
September 1st, 2017
Preventive Services: Hepatitis C Virus (HCV) Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Hepatitis C Virus (HCV) Screening....
September 1st, 2017
Preventive Services: Human Immunodeficiency Virus (HIV) Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 4th, 2018
The following information from the Medicare Learning Network provides guidance on Human Immunodeficiency Virus (HIV) Screening....
September 1st, 2017
Preventive Services: Influenza Virus Vaccine and Administration
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 4th, 2018
The following information from the Medicare Learning Network provides guidance on Influenza Virus Vaccine and Administration....
September 1st, 2017
Preventive Services: Initial Preventive Physical Examination (IPPE)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance on Initial Preventive Physical Examination (IPPE)......
September 1st, 2017
Preventive Services: Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)....
September 1st, 2017
Preventive Services: Intensive Behavioral Therapy (IBT) for Obesity
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Intensive Behavioral Therapy (IBT) for Obesity....
September 1st, 2017
Preventive Services: Lung Cancer Counseling and Annual Screening for Lung Cancer With LDCT
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Lung Cancer Screening Counseling, and Annual Screening for Lung Cancer With Low Dose Computed Tomography (LDCT)....
September 1st, 2017
Preventive Services: Medical Nutrition Therapy (MNT)
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Medical Nutrition Therapy (MNT)....
September 1st, 2017
Preventive Services: Pneumococcal Vaccine and Administration
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Pneumococcal Vaccine and Administration....
September 1st, 2017
Preventive Services: Prostate Cancer Screening
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Prostate Cancer Screening....
September 1st, 2017
Preventive Services: Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening for Cervical Cancer with Human Papillomavirus (HPV) Tests....
September 1st, 2017
Preventive Services: Screening for STIs and High Intensity Behavioral Counseling (HIBC) to Prevent STIs
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.....
September 1st, 2017
Preventive Services: Screening Mammography
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on a Screening Mammography....
September 1st, 2017
Preventive Services: Screening Pap Tests
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening Pap Tests....
September 1st, 2017
Preventive Services: Screening Pelvic Examinations
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening Pelvic Examinations (includes a clinical breast examination)....
August 24th, 2017
Can They Deny Electrical Stimulation by Saying There is no Evidence that it Works?
By Dr Ronald J. Farabaugh | Published August 24th, 2017 - Last Review/Update February 5th, 2019
Topic: Electrical Stimulation (EMS)
Question: An orthopedic surgeon/IME recommended a denial for all electrical stimulation
(EMS) by stating that "according ODG electrical stimulation is experimental therefore not
medically necessary or eligible for reimbursement." Is that true?
August 8th, 2017
Delegation to Staff is not Allowed. Can I Bill for Group Exercises if I Supervise?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published August 8th, 2017 - Last Review/Update February 5th, 2019
My state does not allow me to delegate the supervision of therapeutic exercises (97110). I am the licensed chiropractor. If I provide the constant attendance myself, can I do it for a group of patients? If so, how do I document and bill for this?
August 4th, 2017
Proposed Telehealth Changes for 2018
By Wyn Staheli | Published August 4th, 2017 - Last Review/Update October 4th, 2017
Medicare has proposed making some changes to policies regarding telehealth services. They are adding some new codes to their covered list of telehealth services and propose eliminating the requirement to use the GT modifier. Since many payers adopt similar policies, watch for further announcements from other third-party payers.
Proposed Codes
HCPCS code G0296 ...
August 1st, 2017
Global Surgery
By Find-A-Code | Published August 1st, 2017 - Last Review/Update January 31st, 2018
The Medicare Learning Network provides guidance on the global surgical package
July 13th, 2017
Our Claims are Being Rejected
By ChiroCode | Published July 13th, 2017 - Last Review/Update February 8th, 2019
Question: Our claims are being rejected. We think it is related to our diagnosis codes. What is the reason for this?
June 28th, 2017
Medicare Announces New Cards to Be Issued
By Dr. Mario Fucinari, Author & Member of the Carrier Advisory Committee for Medicare | Published June 28th, 2017 - Last Review/Update February 8th, 2019
Identity theft has become a major problem in the United States. As a prevention measure, the Centers for Medicare& Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars.
June 23rd, 2017
Psychiatric / Psychological Testing with Bill Type 12X
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 23rd, 2017 - Last Review/Update July 26th, 2017
Providers submitting claims with bill type 12X are to report revenue code 0918 (psychiatric / psychological testing).
Note:
Revenue codes do not apply to physicians; other professionals and suppliers bill these services to the Part B MAC
They are used only with providers who bill these services to the fiscal intermediary or Part ...
June 13th, 2017
Modifier GY for Chiropractic
By ChiroCode | Published June 13th, 2017 - Last Review/Update January 31st, 2019
Q. Is there a modifier that can be added on to CPT codes to show we performed the service even though they are bundled charges or Medicare doesn't pay for them? For example 97140 billed to BCBS or 99202 billed to Medicare. Is the GY modifier for all insurance companies or just Medicare?
April 28th, 2017
Can I be Forbidden from Billing 99204 or 99214?
By ChiroCode | Published April 28th, 2017 - Last Review/Update January 31st, 2019
Q: An insurer told me that chiropractors cannot bill 99204 or 99214 because those exams "require a level of decision making that would typically only occur in an emergency room." Is this true? Do I have any recourse?
March 3rd, 2017
Chiropractic Manipulation
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published March 3rd, 2017 - Last Review/Update February 8th, 2019
Q: If a patient is treated with chiropractic manipulation and it is clinically appropriate but doesn't qualify as medically necessary care, what is the proper way to communicate this when billing the insurance company for the service?
March 1st, 2017
Care Plan Oversight Services
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 1st, 2017 - Last Review/Update January 16th, 2018
Care Plan oversight services is commonly done but rarely billed. The following codes can only be billed once every 30 days. The use of the following codes are determined by the complexity and approximate time spent by the physician or other health care professional within a 30-day period.
G0179
MD re-certification HHA PT
May be ...
February 24th, 2017
Using Time Span Codes
By Find-A-Code | Published February 24th, 2017
The date of service (DOS) is the reference point for determining the frequency of code submission and subsequent reimbursement during that period, generally if the service was provided in a different calendar month, the service would qualify for reimbursement.
Modifiers will not override a time span code if it is billed with ...
February 16th, 2017
Diagnostic Criteria for Behavioral Health
By Wyn Staheli, Director of Research | Published February 16th, 2017
In order to arrive at a diagnosis and check for related complications, a healthcare provider needs to evaluate the patient condition. This may include:
History: This can include the patient's personal history as well as that of the patient's family.
Physical exam: The healthcare provider will try to rule out physical problems ...
February 6th, 2017
Q/A: Would Leaving Box 14 on the 1500 Claim Form Blank Cause Denials?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published February 6th, 2017 - Last Review/Update February 8th, 2019
We have been leaving box 14 on the 1500 claim form blank for Medicare claims and are getting denials. Could this be why?
January 6th, 2017
Assistant-At-Surgery Services
By Brittney Murdock, QCC, CMCS, CPC | Published January 6th, 2017
An "assistant at surgery" is a physician who actively assists the physician in charge of a case in performing a surgical procedure. The "assistant at surgery" provides more than just ancillary services.
Codes eligible for reimbursement for an assistant surgeon are designated by the Centers for Medicare and Medicaid Services (CMS) ...
December 21st, 2016
Q/A: E/M Bundled with CMT
By ChiroCode | Published December 21st, 2016 - Last Review/Update February 28th, 2019
What do you do when you are continually getting denials when billing office visit E/M code 99213-25 along with a CMT on dates that we do re-exams? What do you do when an appeal does not seem to work even though clear evidence has been provided that all conditions for the 99213 have been satisfied.?
December 7th, 2016
Discounts
By Wyn Staheli, Director of Research | Published December 7th, 2016
All healthcare providers need to be aware that there are both appropriate and inappropriate ways to discount your fees. Both state and federal laws can impact your practice financial policy regarding fee discounts. Additionally, we recommend carefully reviewing either Chapter 1.5-Fees of the Behavioral Health DeskBook or the Insurance and Reimbursement chapter ...
December 7th, 2016
Insurance Denying Everything as Maintenance
By ChiroCode | Published December 7th, 2016 - Last Review/Update March 4th, 2019
Are you having a difficult time getting reimbursed? Are claims being denied because the insurance classifies everything as maintenance?
November 30th, 2016
When can I Bill for a Consult E/M Code?
By | Published November 30th, 2016 - Last Review/Update March 5th, 2019
Physician referrals -- When can we bill a consult code? If we do not have the referral on our referral pad can we bill the consult code?
November 21st, 2016
Best Diagnosis Codes for E-stim
By ChiroCode | Published November 21st, 2016 - Last Review/Update March 5th, 2019
What are the best diagnosis codes for E-stim?
November 9th, 2016
Should I Avoid Billing 97112
By Raquel Shumway | Published November 9th, 2016 - Last Review/Update March 5th, 2019
Question: The Doctor says he was told by a billing company a few years ago to avoid the 97112. So he has been doing 97110 instead. They do the items listed in 97110, but often some of the ones in 97112 as well. His question was, should he actually be avoiding 97112? Or is there simply something he needs to be mindful of when using it?
October 11th, 2016
How to Handle Billing for a Patient With Multiple Plans
By ChiroCode | Published October 11th, 2016 - Last Review/Update March 4th, 2019
In the case of a patient who has multiple plans, which plan is primary and which is secondary?
October 3rd, 2016
Q/A: When should we update Box 14 on the claim form?
By ChiroCode | Published October 3rd, 2016 - Last Review/Update March 4th, 2019
When to update Box 14 on the CMS 1500 claim form.
August 24th, 2016
Getting Ready for new ICD-10 Codes for Chiropractic
By ChiroCode | Published August 24th, 2016 - Last Review/Update March 5th, 2019
ICD-10-CM changes for 2017 include 1,974 new codes, 311 deleted codes, and 425 revised codes. Chiropractors, fortunately, are only affected by about 70 of these changes. And none of them are ground breaking. However, if you report deleted codes, your claims could be denied. Read more to see some examples of the changes
July 29th, 2016
Can we bill a low level E/M with every procedure?
By | Published July 29th, 2016
Can’t we bill a low level E/M with every procedure? No! Medicare says this: Per CCI (chapter 11, Letter R.): “The decision to perform a minor surgical procedure is included in the payment for the minor surgical procedure and should not be reported separately as an E/M service. However, a...
June 28th, 2016
Key Terms in ICD-10
By ChiroCode | Published June 28th, 2016 - Last Review/Update March 5th, 2019
In some places, the ICD-10-CM code set uses words we think we are familiar with. However, a review of the guidelines shows that some of these words have very specific definitions. Here are a few important ones to remember.
June 28th, 2016
Q&A: We Bill Hot/Cold Packs (97010) but are Rarely Reimbursed. Why is This?
By ChiroCode | Published June 28th, 2016 - Last Review/Update March 5th, 2019
97010 is a service that is commonly not covered by payers or if it is covered, reimbursement is very minimal. This is due to a few reasons:
June 21st, 2016
Voluntary Overpayments
By Wyn Staheli, Director of Research | Published June 21st, 2016
When a claim has been determined to be paid more than the allowed amount, it is considered an overpayment. The action to be taken depends on how the overpayment is discovered. This article covers voluntary overpayment refund procedures as well as a Voluntary Overpayment Form.
June 16th, 2016
Q&A: Will Using Lower Level Codes Reduce Our Chances of Being Audited?
By ChiroCode | Published June 16th, 2016 - Last Review/Update March 5th, 2019
Q&A: If we use low level codes on each visit (such as 98940, 99212, 99202), will our chances of being audited be less than if we billed higher level codes?
June 9th, 2016
Understanding and Using Taxonomy Codes to Maximize Reimbursement
By | Published June 9th, 2016
Taxonomy codes are used by insurers as indicators of legal scope of practice. Scope of practice is key to getting reimbursed under the Affordable Care Act or ObamaCare. However, Most providers will only choose one taxonomy code to describe their training. This limits their scope of practice. To maximize scope ...
June 7th, 2016
A dental guide to cross-coding for oral cancer screening
By Christine Taxin | Published June 7th, 2016 - Last Review/Update January 30th, 2017
It is possible to bill medical insurance in the dental office for oral cancer testing. This will show you how
May 26th, 2016
Groupon: Is it worth the risk?
By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published May 26th, 2016 - Last Review/Update March 5th, 2019
Our team is frequently asked if it is legal for chiropractic offices to offer coupons or Groupons. We’re not allowed, as a profession, to dramatically discount our services, offer free treatments, or provide gifts or free meals for potential patients. Any one of these things can be considered an “inducement.” Practices that improperly induce patients to seek care or services, for example, by providing coupons for care or supplies, may find that they are in violation of the law if they aren’t careful.
So what will that mean to you and your practice? It isn’t pretty.
May 25th, 2016
EOB Problems
By | Published May 25th, 2016
Have you had to send money back to a dental insurance company? You may have received a letter informing you that a patient received benefits but then turned out to be ineligible and now the insurance company wants their money back. Hopefully, you sent them a check for the amount ...
March 28th, 2016
Q&A: Is There a Better Supply Code to Use Than 99070?
By ChiroCode | Published March 28th, 2016 - Last Review/Update March 5th, 2019
Are there more specific codes for supplies rather than using 99070?
March 14th, 2016
Q/A: What is the Best Way to Handle Denials?
By ChiroCode | Published March 14th, 2016 - Last Review/Update March 5th, 2019
What is the best way to handle denials?
March 4th, 2016
What is an 'Other Qualified Healthcare Professional'?
By Wyn Staheli | Published March 4th, 2016
What's the difference between a physician, an other qualified healthcare professional, clinical staff and individual.
February 24th, 2016
Nebulizer Therapy Billing Reminders - Modifiers, Dispensing Fees, and Orders
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 24th, 2016 - Last Review/Update August 3rd, 2017
The ICD-10-CM code describing the condition necessitating nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs.
When ever a unit dose code is billed, it must have a KO, KP, or KQ modifier. (Exception: The KO, KP, and KQ modifiers should not be used with code J7620.)
When billing miscellaneous equipment or accessories (E1399), the claim must ...
February 17th, 2016
TeleMedicine Terms and Definitions and who can bill - Using Modifiers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 17th, 2016 - Last Review/Update August 4th, 2017
Medical practitioners who can bill for a covered Telehealth service vary by state law, but they may include:
physician,
nurse practitioner,
physician assistant,
nurse midwife,
clinical nurse specialist,
clinical psychologist,
clinical social worker, and
registered dietician or nutrition professional
Distant or Hub site: Site at which the physician or other licensed practitioner delivering the service is located at the time the ...
February 15th, 2016
Q&A: How do You Code for a Bilateral Condition, Such as Sciatica?
By ChiroCode | Published February 15th, 2016 - Last Review/Update March 5th, 2019
How do you code for a bilateral condition, such as sciatica?
February 8th, 2016
How do we Know Which Codes a Payer will Allow?
By ChiroCode | Published February 8th, 2016 - Last Review/Update April 26th, 2019
Question:
How do we know which codes a payer will allow?
February 1st, 2016
Will Incident-To in Your Organization Pass a Compliance Audit?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 1st, 2016
Practices that bill incident to services need to periodically audit compliance with Medicare and private payor guidelines to avoid potential denials or third-party audits.
January 29th, 2016
Billing Dates with ICD-10-CM
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 29th, 2016
Be sure to use the code set that is effective and valid for the date of service the patient was seen or your claim will be denied.You cannot submit ICD-9-CM codes on a claim for any encounter after October 1, 2015.
A claim cannot contain both ICD-9-CM and ICD-10-CM codes, it ...
January 8th, 2016
What are External Cause Codes in ICD-10?
By ChiroCode | Published January 8th, 2016 - Last Review/Update September 3rd, 2019
Chapter 20 External Causes of Morbidity includes codes from V00 to Y99. They were greatly expanded in ICD-10-CM.
January 6th, 2016
Don’t expect to see payment any time soon for ‘telephone consults’
By Codapedia | Published January 6th, 2016
Four new CPT® codes that got some attention when the 2014 CPT® changes were released late last year were a new E/M code series, 99446-99449, designed to be reported when a consulting provider offered a telephone or Internet E/M service that included a verbal and written...
January 6th, 2016
CMS-1500 form revised to fit more diagnosis codes, less patient demographic information
By Codapedia | Published January 6th, 2016
CMS-1500 form revised to fit more diagnosis codes, less patient demographic informationIt doesn’t get used nearly as much as it used to, but there is a new CMS-1500 claim form that has been revised slightly to fit more diagnosis codes and to facilitate the transition to...
January 6th, 2016
As of 01/01/14, your practice can insist of electronic funds transfer payments from payers
By Codapedia | Published January 6th, 2016
One provision of the Affordable Care Act (ACA) that can work to your practice’s advantage is Section 1104, which gives you the right to insist on electronic funds transfer (EFT) as your method of payment. As of Jan. 1, 2014, you are entitled to EFT...
December 21st, 2015
ABN - Our Office's Process
By Codapedia | Published December 21st, 2015
In an attempt to make the ABN more understandable for my physicians and staff, I developed this explanatory paper that is specific to our office; however, the basics apply to all offices. Charlene Burgett,MS-HCM,CMA(AAMA),CPC,CCP,CMSCS,CPMAdministrator, North Scottsdale Family MedicinePOMAA National Advisory Board charlene_burgett@yahoo.comInvite me on LinkedIn: http://www.linkedin.com/in/charleneburgett...
December 11th, 2015
CMS: Lot of errors billing psychotherapy services when E/M visit is involved
By Codapedia | Published December 11th, 2015
The Comprehensive Error Rate Testing (CERT) program Medicare uses to assess the accuracy of provider billing has uncovered a big source for mistakes – documentation problems when a patient is receiving psychotherapy services on the same date as an E/M encounter, according to CMS. There are...
December 11th, 2015
Consult Documentation Guidelines
By Codapedia | Published December 11th, 2015
For those practices that bill consultation codes, the guidelines can be confusing. Yet, it is worth taking the time to learn the rules to get the additional reimbursement paid for consultation codes over new patient codes. Remember the following: · There must be written...
December 11th, 2015
‘Two midnight’ rule draws lawsuit – enforcement currently delayed
By Codapedia | Published December 11th, 2015
The American Hospital Association is leading the charge in a lawsuit against CMS’s controversial “two-midnight rule,” instituted last year to attempt to slow down the expanded use of observation status by hospitals by presuming that any stay intended to cover two or more midnights would be...
December 11th, 2015
Hospital discharge, nursing facility admit billable on same day by same provider in most instances
By | Published December 11th, 2015
Medicare will typically pay for a hospital discharge service (billed with 99238-99239) and a nursing facility admission visit (99304-99306) when billed on the same date of service (DOS) by the same provider without the need for a modifier. As always, however, there are a couple...
December 11th, 2015
Selecting a Third-Party Collection Agency and Choosing the Correct Collection Program
By Codapedia | Published December 11th, 2015
Increasing cash flow through the use of a modern, third-party collection agency is a must for practice survival. With states reducing government funding and third-party payers reducing allowables, more and more dollars are being transferred to patient responsibility. Practices now must trim operating expenses and...
December 11th, 2015
Charge capture: Paper and Electronic Encounter Forms
By Codapedia | Published December 11th, 2015
Physicians and Non-Physician Practitioners (NPPs) may want to distance themselves from coding, but implementing an Electronic Health Record (EHR) moves them in the opposite direction. If using an EHR, after completing the note, the clinician selects the CPT® and ICD-9 codes (the procedure and diagnosis...
December 11th, 2015
Who Qualifies for TCM Services?
By Codapedia | Published December 11th, 2015
Any patient post-discharge whose medical and/or psychosocial problems are complex enough to require TCM services qualifies for these codes. Here are the specifics: 1. Location: “TCM is for higher-risk patients being discharged from an inpatient or observation status to their home, rest home, or assisted living...
December 11th, 2015
Graphical Coding as part of EMR clinical workflow
By Codapedia | Published December 11th, 2015
The way to ensure a high performing EMR implementation is to fundamentally rethink processes to match what is technologically appropriate, rather than automating existing workflows. Instead of using the existing HIT EMR systems from the major vendors as the workflow driver, start with a sample of...
December 11th, 2015
Modifier -24 - Indications for Use
By Codapedia | Published December 11th, 2015
Modifier 24 is used to indicate that an Evaluation and Management service was provided by the surgeon to a patient within the global period of a major or minor surgery. The claim must be accompanied by documentation that supports that the service is not...
December 11th, 2015
Billing for no-shows
By Codapedia | Published December 11th, 2015
CMS clarified in 2007 that a physician practice may bill Medicare patients for failing to keep an appointment. The CMS MedLearn matters article is attached as a resource. Check with your state Medicaid to see if you can bill Medicaid patients. If you are billing Medicare...
December 11th, 2015
How to bill for Well Woman Exams (WWE)
By Codapedia | Published December 11th, 2015
Well Woman Exam CodingThere are options for billing pelvic exams and Pap smears for non-Medicare payers, albeit inconsistently by health plan. Some health plans will pay G0101, Q0091, S0610 and/or S0612. Some will pay one or another, some will pay a combination of two, others...
December 11th, 2015
Incident to Billing or Incident to Service
By Codapedia | Published December 11th, 2015
This question appeared in a recent list serve. My two responses are based upon two different assumptions: (1) both providers are physicians, and (2) one of the providers is not a physician. The principal points are that each physician has a unique National...
December 3rd, 2015
Why Get Into Medical Billing?
By Codapedia | Published December 3rd, 2015
I am asked alot or read alot where people want to get into medical billing. Some have gone to school and some haven't. Either way, there is more to it than just saying, I want to do that. I've been in this field for over...
December 3rd, 2015
Post-operative Hospital Visits
By | Published December 3rd, 2015
In 1992, CMS developed the concept of the Global Surgical Package, which pays for surgical services with a single payment. The full description of services that are included in this payment is described in the Medicare Claims Processing Manual, Chapter 12, Section 40 and...
December 3rd, 2015
The Critical Role Of Hospital CFOs: A Data Driven Answer [Infographic]
By | Published December 3rd, 2015
We know the evolving role of CFOs in the healthcare industry. There are situations which have forced the executives to make such decisions like changing the vendor, attritions and outsourcing one or more of their processes. There could be ample reasons like transition to value-based model, slow payer procedures, low...
December 3rd, 2015
How to research coding questions with Codapedia.com
By | Published December 3rd, 2015
How to Research Answers to Coding Questions Perform a search of the discussion board or listserv website prior to posting a new question. For your search terms, include specific words such as the diagnostic statement or procedure statement or the specific code number or the...
November 24th, 2015
Prescription (order) Requirements for Durable Medical Equipment
By | Published November 24th, 2015
The supplier for all Durable Medical Equipment, Prosthetic, and Orthotic Supplies (DMEPOS) is required to keep on file a physician prescription (order). A supplier must have an order from the treating physician before dispensing any DMEPOS item to a beneficiary.
November 20th, 2015
No Claim Left Behind - Be a Persistent Biller
By Codapedia | Published November 20th, 2015
Call me crazy, but it is always exciting to me when I assist a practice in getting reimbursed on unpaid or delinquent claims. Claims that were denied, viewed as uncollectable, past filing deadline, or a multitude of other reasons. I even have a little...
November 19th, 2015
Money In Your Pocket: Balance Bill
By Codapedia | Published November 19th, 2015
Do you routinely balance bill your patients? Do you send the statement as soon as you hear from insurance or do you wait until the end of the month?
Balance billing your patients is essential for several reasons. First, it increases your revenue. It may not seem like ...
November 19th, 2015
Can consults be billed based on time?
By | Published November 19th, 2015
Yes, both inpatient and outpatient consults may be coded based on time, when the conditions for using time are met.
CPT® tells us that a physician or NPP may use time to select a code when counseling "dominates" the visit. CMS confirms these rules in their Documentation Guidelines. ...
October 5th, 2015
Reporting Laterality Still Requires Modifiers
By Wyn Staheli, Director of Research | Published October 5th, 2015
One of the significant coding changes with ICD-10-CM was including laterality within the code itself. This concept should help reduce billing errors and claim denials. Interestingly, CMS issued a statement regarding the reporting of laterality in their provider newsletter (emphasis added).
Implementation of ICD-10-CM will not change the reporting of Current Procedural Terminology ...
September 11th, 2015
Essential Health Benefits (EHBs)
By Wyn Staheli, Director of Research | Published September 11th, 2015 - Last Review/Update February 25th, 2016
Information about the mandated Essential Health Benefits (EHBs). Includes links and other helpful information.
August 31st, 2015
Working with Medicare in the Dental Practice
By Christine Taxin | Published August 31st, 2015
Dental practices that do not work with medical are truly confused when it comes to Medicare. I decided to put together a simple outline of what we should be doing to be compliant with Medicare.
August 19th, 2015
Billing injections on the same day as an E/M service
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 19th, 2015
But increasingly, payers are being just as reflexive when it comes to denying the E/M service, saying that it's bundled into the injection.
What's the truth? While there are many instances when the E/M service is bundled into the injection service, there are probably just as many instances when these denials ...
August 19th, 2015
G-Codes for Functional Reporting and Severity/Complexity Modifiers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 19th, 2015
Beginning January 1, 2013, Functional Reporting requires therapy practitioners and providers to report non-payable G-codes and modifiers to convey information about the beneficiary’s functional status including projected goal status throughout the episode of care.
For the severity modifiers, providers should include a description of how the modifiers were determined.
Functional ...
August 10th, 2015
Compound Drugs - How to bill
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2015
Pharmacy compounding is a has been done for many years, it is a tradition that offers customized care to meet the specific needs of individual patients. Modern technology and innovative techniques with research have allowed more pharmacist to customize medication to meet a patients needs.
Through compounding, a prescriber and pharmacist can adjust ...
August 10th, 2015
Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2015 - Last Review/Update August 7th, 2017
Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech - language pathology services. They should never be used with codes that are not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy ...
August 3rd, 2015
Levels of Care Data Required on the Institutional Claim to Medicare Contractor
By | Published August 3rd, 2015
With the exception of payment for physician services, Medicare payment for hospice care is made at one of four predetermined rates for each day that a Medicare beneficiary is under the care of the hospice. The four rates are prospective rates; there are no retroactive adjustments other than the application ...
August 3rd, 2015
Method for Computing Fee Schedule Amount (Rev. 1, 10-01-03)
By | Published August 3rd, 2015
B3-15006
The CMS continually updates, refines, and alters the methods used in computing the fee schedule amount. For example, input from the American Academy of Ophthalmology has led to alterations in the supplies and equipment used in the computation of the fee schedule for selected procedures. Likewise, new research has changed ...
August 3rd, 2015
Medicare Physicians Fee Schedule (MPFS) (Rev.1, 10-01-03)
By Find-A-Code | Published August 3rd, 2015
Carriers pay for physicians’ services furnished on or after January 1, 1992, on the basis of a fee schedule. The Medicare allowed charge for such physicians’ services is the lower of the actual charge or the fee schedule amount. The Medicare payment is 80 percent of the allowed charge after ...
August 3rd, 2015
Medicare Secondary Payer
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 3rd, 2015
Medicare Secondary Payer (MSP) is the term generally used when the Medicare program does not have primary payment responsibility - that is, when another entity has the responsibility for paying before Medicare.
Primary payers are those that have the primary responsibility for paying a claim. Medicare remains the primary payer for ...
July 20th, 2015
Hospice Pre - Election Evaluation and Counseling Services (Rev. 2258)
By Find-A-Code | Published July 20th, 2015
Effective January 1, 2005, Medicare allows payment to a hospice for specified hospice pre-election evaluation and counseling services when furnished by a physician who is either the medical director of or employee of the hospice.
Medicare covers a one-time only payment on behalf of a beneficiary who is terminally ill, (defined ...
July 17th, 2015
Claims Processing Requirements for Deported Beneficiaries (Rev. 943, Issued: 05-05-06)
By Find-A-Code | Published July 17th, 2015
Section 202(n) of the Social Security Act (the Act), requires the termination of Title II benefits upon deportation. Moreover, Sections 226 and 226(A) of the Act provide that no payments may be made for benefits under Part A of Title XVIII of the Act if there is no monthly benefit ...
July 17th, 2015
Implementation of Payment Policy for Deported Medicare Beneficiaries (Rev. 943, Issued: 05-05-06)
By Find-A-Code | Published July 17th, 2015
A. CWF Editing of Claims
1. An auxiliary file shall be established in the Common Working File to contain deportation status.
2. This auxiliary file will be the basis for an edit that rejects claims submitted by Medicare contractors.
3. The edit will reject a claim where the beneficiary HIC number on ...
July 17th, 2015
Provider Assignment to FIs and MACs (Rev. 1707; Issued: 03-27-09)
By Find-A-Code | Published July 17th, 2015
A. The Process of Moving Providers from FIs to MACs
1. The General Case
An existing Medicare provider with a claims history will remain in its current workload assignment. As each MAC contract is awarded, the new MAC will take over workload from the carriers and FIs that serviced the state(s) in ...
July 17th, 2015
FI Service to HHAs and Hospices (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
Under 42 CFR 421.117, CMS is authorized to designate RHHIs to service HHAs and hospices. This provision was implemented through the designation of regional FIs to service all HHAs and hospices. See http://www.cms.hhs.gov/contacts/incardir.asp for RHHI jurisdictions.
An HHA or hospice chain may request to be served under an arrangement involving a ...
July 17th, 2015
CMS No Longer Accepts Provider Requests to Change Their FI (Rev. 2876, Issued: 02-07-14)
By Find-A-Code | Published July 17th, 2015
Medicare providers will no longer be able to request a change of FI, they must remain with the FI to which they have been assigned.
Pub 100-04 Medicare Claims Processing Manual
...
July 17th, 2015
Provider Participation (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
The RO uses the provider tie-in notice, Form CMS-2007 (see the CMS forms page at http://www.cms.hhs.gov/forms/), as an official notification to the FI of a change in its list of providers. The RO completes and transmits a Form CMS-2007 to the home office of the FI in each of the ...
July 17th, 2015
Content and Terms of Provider Participation Agreements (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
In the agreement/attestation statement signed by a provider serviced by an FI, the provider agrees to maintain its compliance with all of the conditions for certification in 42 CFR 491. If a provider fails to maintain compliance with one or more of the conditions, it must promptly report this (usually ...
July 17th, 2015
Provider Charges to Beneficiaries (Rev. 2921, Issued: 04-04-14)
By Find-A-Code | Published July 17th, 2015
In the agreement/attestation statement signed by a provider, it agrees not to charge Medicare beneficiaries (or any other person acting on a beneficiary’s behalf) for any service for which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program. This includes items or services for ...
July 17th, 2015
Charges to Hold a Bed During SNF Absence (Rev. 1522, Issued: 05-30-08)
By Find-A-Code | Published July 17th, 2015
Charges to the beneficiary for admission or readmission are not allowable. However, when temporarily leaving a SNF, a resident can choose to make bed-hold payments to the SNF.
Bed-hold payments are readily distinguishable from payments made prior to initial admission, in that the absent individual has already been admitted to the ...
July 17th, 2015
Provider Refunds to Beneficiaries (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
In the agreement between CMS and a provider, the provider agrees to refund as promptly as possible any money incorrectly collected from Medicare beneficiaries or from someone on their behalf.
Money incorrectly collected means any amount for covered services that is greater than the amount for which the beneficiary is liable ...
July 17th, 2015
Provider Treatment of Beneficiaries (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
In the agreement between CMS and a provider, the provider agrees to accept Medicare beneficiaries for care and treatment. The provider cannot impose any limitations with respect to care and treatment of Medicare beneficiaries that it does not also impose on all other persons seeking care and treatment. If the ...
July 17th, 2015
Assignment of Provider’s Right to Payment (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
Except as provided in §30.2.1, FIs pay benefits due a provider only to the provider.
Carriers may pay assigned benefits only to the physician, practitioner, or supplier who furnished the service. They do not pay the benefits to any other person or organization under an assignment or reassignment, power of attorney, ...
July 17th, 2015
Exceptions to Assignment of Provider’s Right to Payment – Claims Submitted to A/B MACs (Rev. 1931, Issued: 03-12-10)
By Find-A-Code | Published July 17th, 2015
A. Payment to Government Agency
Medicare payment for the services of a provider is not made to a governmental agency or entity except when payment to the governmental agency or entity is permissible under the other listed reassignment exceptions, e.g., where the agency is the employer of the physician.
B. Payment ...
July 17th, 2015
Background and Purpose of Reassignment Rules - Claims Submitted to B/MACs (Rev. 1931, Issued: 03-12-10)
By Find-A-Code | Published July 17th, 2015
In 1972, Congress acted to stop a practice under which some physicians and other suppliers providing covered services reassigned their Medicare and Medicaid receivables to other organizations and groups, which then claimed and received payment. Often the organizations acquired the claims at a percentage of face value. It had become ...
July 17th, 2015
Reassignments by Nonphysician Suppliers - Claims Submitted to FIs (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
Definition of Participating From MIM 3005
Nonphysician suppliers may reassign benefits under conditions similar to those under which physicians reassign benefits. Note, however, that when a supplier furnishes services to patients of a participating provider (e.g., a participating hospital or SNF) under arrangement (within the meaning of §1861(w) of the ...
July 17th, 2015
Effect of Payment to Ineligible Recipient (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
An otherwise correct Medicare payment made to an ineligible recipient under an assignment or other authorization by the provider does not constitute a program overpayment. Sanctions may be invoked against a provider (see §30.2.15) to prevent it from executing or continuing in effect such an authorization in the future. Neither ...
July 17th, 2015
Payment to Agent - Claims Submitted to Carriers (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
A. Conditions
The FI or carrier makes payment in the name of the provider (Carriers additionally may pay in the name of supplier or employer, facility, or organized health care delivery system.) to an agent who furnishes billing or collection services if:
• The agent receives the payment under an agreement ...
July 17th, 2015
Payment to Bank (Rev. 213, 06-25-04)
By Find-A-Code | Published July 17th, 2015
Medicare payments due a provider or supplier of services may be sent to a bank (or similar financial institution) for deposit in the provider/supplier’s account so long as the following requirements are met:
• The bank may provide financing to the provider/supplier, as long as the bank states in writing, in ...
July 17th, 2015
Payment to Employer of Physician - Carrier Claims Only (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
The carrier may pay Part B benefits for covered physician services under an assignment or for enrollees that did not execute assignment before death to the physician’s employer, provided that under the terms of the physician’s employment, only the employer and not the physician has the right to charge or ...
July 17th, 2015
Payment for Services Provided Under a Contractual Arrangement - Carrier Claims Only (Rev. 472, Issued: 02-11-05)
By Find-A-Code | Published July 17th, 2015
A carrier may make payment to an entity (i.e., a person, group, or facility) enrolled in the Medicare program that submits a claim for services provided by a physician or other person under a contractual arrangement with that entity, regardless of where the service is furnished. Thus, the service may ...
July 17th, 2015
University-Affiliated Medical Faculty Practice Plans - Claims Submitted to Carriers (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
A carrier may make Part B payment to a university-affiliated medical faculty practice plan that has the following attributes:
• There is a written agreement between the Governing Board of the University and the Governing Board of the Medical Faculty Practice Plan describing the relationship between both parties.
• The Medical Faculty ...
July 17th, 2015
Indirect Payment Procedure (IPP) - Payment to Entities that Provide Coverage Complementary to Medicare Part B (Rev. 2896, Issued: 03-07-14)
By Find-A-Code | Published July 17th, 2015
Medicare Part B payment otherwise payable to a beneficiary for the services of a physician or supplier who charges on a fee-for-service basis may be paid to an entity using the indirect payment procedure (IPP). Any entity registered in accordance with the instructions in Pub. 100-08, chapter 15, sections 15.7.9 ...
July 17th, 2015
Payment to Physician or Other Supplier for Diagnostic Tests Subject to the Anti-Markup Payment Limitation - Claims Submitted to A/B MACs (B) (Rev. 3089, Issued: 10-21-14)
By Find-A-Code | Published July 17th, 2015
(Rev. 3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming April 1, 2015 - For Testing and Implementation; ImplementationJanuary 5, 2015, April 6, 2015 – For MAC testing of PECOS changes only)
A physician or other supplier may bill for the technical component (TC) and/or professional ...
July 17th, 2015
Payment Under Reciprocal Billing Arrangements - Claims Submitted to Carriers (Rev. 1486, Issued: 04-04-08)
By Find-A-Code | Published July 17th, 2015
The patient’s regular physician may submit the claim, and (if assignment is accepted) receive the Part B payment, for covered visit services (including emergency visits and related services) which the regular physician arranges to be provided by a substitute physician on an occasional reciprocal basis, if:
• The regular physician is ...
July 17th, 2015
Physician Payment Under Locum Tenens Arrangements - Claims Submitted to Carriers (Rev. 1486, Issued: 04-04-08)
By Find-A-Code | Published July 17th, 2015
A. Background
It is a longstanding and widespread practice for physicians to retain substitute physicians to take over their professional practices when the regular physicians are absent for reasons such as illness, pregnancy, vacation, or continuing medical education, and for the regular physician to bill and receive payment for the ...
July 17th, 2015
Establishing That a Person or Entity Qualifies to Receive Payment on Basis of Reassignment - for Carrier Processed Claims (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
Any person or entity wishing to receive Part B payment as a reassignee of one or more physicians (or other practitioner or supplier), or as the supplier of the services, must furnish to the carrier sufficient information to establish clearly that it qualifies to receive payment for those services. Where ...
July 17th, 2015
Billing Procedures for Entities Qualified to Receive Payment on Basis of Reassignment - for A/B MAC (B) Processed Claims (Rev. 3086, Issued: 10-03-14)
By Find-A-Code | Published July 17th, 2015
Except where otherwise noted, the following procedures apply to both assigned and unassigned claims submitted by medical groups and other entities entitled to bill and receive payment for physician services under §§30.2-30.2.8. They are used whether the charges are compensation related or non-compensation related.
A General
Chapter 26 contains general claims ...
July 17th, 2015
Correcting Unacceptable Payment Arrangements (Rev. 1931, Issued: 03-12-10
By Find-A-Code | Published July 17th, 2015
A. Disseminating Information
From time to time, A/B MACs must disseminate through professional relations media information regarding the prohibition in §30.2.
A/MACs
The following language may be used by A/MACs or adapted for this purpose: The Medicare law prohibits us from paying benefits due a provider to another person or organization ...
July 17th, 2015
Questionable Payment Arrangements (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
A. Developing Questionable Payment Arrangements
Contractors (both FIs and Carriers) should assume that an arrangement in which Medicare payment is being sent or is to be sent to an address other than the physical location of the provider/supplier is consistent with the requirements of §30.2 in the absence of evidence ...
July 17th, 2015
Sanctions for Prohibited Payment Arrangement (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
A. Advice to Provider
If the contractor finds that a provider (for Part B, physician or other supplier, or party eligible to receive the payment under §30.2 as an employer, facility or organization) has entered into, or is considering entering into, a payment arrangement prohibited by §30.2, the contractor must ...
July 17th, 2015
Prohibition of Assignments by Beneficiaries
By Find-A-Code | Published July 17th, 2015
A. Basic Prohibition
Except as provided in subsection B, carriers pay only the beneficiary (or beneficiary legal representative or representative payee) benefits payable directly to the beneficiary FIs do not send money directly to beneficiaries, they must require providers they pay to refund monies to beneficiaries when circumstances so warrant ...
July 17th, 2015
Physician/Practitioner/Supplier Participation Agreement and Assignment - Carrier Claims (Rev. 1035, Issued: 08-18-06)
By Find-A-Code | Published July 17th, 2015
Institutional providers (those that bill Fiscal Intermediaries (FIs)) are paid direct by the FI. In contrast, physicians, practitioners, and suppliers that bill the carrier may choose to enter into a participation agreement.
Carrier “Participating Providers” are paid at 100 percent of the physician fee schedule and must accept assignment (must accept ...
July 17th, 2015
Mandatory Assignment on Carrier Claims (Rev. 2487, Issued: 06-08-12)
By Find-A-Code | Published July 17th, 2015
The following practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services. This means that they must accept the Medicare allowed amount as payment in full for their practitioner services. The beneficiary’s liability is limited to any applicable deductible plus ...
July 17th, 2015
Processing Claims for Services of Participating Physicians or Suppliers by Carriers (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
The participating physician or supplier submits any claims for services furnished by the physician or supplier, except in the limited circumstances specified in §30.2.8.3 or §30.2.16. (The exception concerns situations where the physician or supplier accepts, as full payment, payment by certain organizations.) When an unassigned claim is received from ...
July 17th, 2015
Nature and Effect of Assignment on Carrier Claims (Rev. 643, Issued: 08-12-05)
By Find-A-Code | Published July 17th, 2015
Assignment is a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to let the physician or other supplier request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. The physician/supplier in return ...
July 13th, 2015
Transfer of Claims Material Between Carrier and Intermediary (FI) (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 13th, 2015
If a beneficiary erroneously submits a Form CMS-1490 (beneficiary-filed claim form) to a carrier with an itemized bill for services that must be paid by the FI, the carrier forwards such claims to the FI for the necessary action. The FI will inform the provider to submit a claim once ...
July 13th, 2015
A DME MAC receives a Paper Claim with Items or Services that are in Another DME MAC's Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 13th, 2015
When a DME MAC receives a claim submitted on the Form CMS-1500 for Medicare payment that should be processed by a DME MAC but was sent to the wrong DME MAC, the claim shall be returned as unprocessable.
Use the following messages:
CARC 109 – Claim not covered by this payer/contractor. You ...
July 13th, 2015
FI Jurisdiction of Requests for Payment (Rev. 1, 10-01-03)
By Find-A-Code | Published July 13th, 2015
The FIs have jurisdiction for the following:
• All Part A services (hospital, SNF, HHA, and hospice);
• Most Part B services from providers that furnish Part A services; and
• Part B facility services from CORFs, Renal; Dialysis Facilities, Rural Health Clinics, Religious Nonmedical Institutions, Outpatient Physical Therapy Centers, Federally Qualified Health ...
July 13th, 2015
FI Payment for Emergency and Foreign Hospital Services (Rev. 1, 10-01-03)
By Find-A-Code | Published July 13th, 2015
A. Beneficiary Services Outside United States - Emergency Hospital Admissions
See chapter 3, for detailed information concerning beneficiary services outside the United States. Generally, payment is made for emergency inpatient hospital services in qualified Canadian or Mexican hospitals in the following circumstances:
• A Medicare beneficiary is in the United States ...
July 13th, 2015
Payments Under Part B for Services Furnished by Suppliers of Services to Patients of a Provider (Rev. 1, 10-01-03)
By Find-A-Code | Published July 13th, 2015
Section 1861(w)(1) of the Act permits a hospital, critical access hospital, skilled nursing facility, home health agency, or hospice to obtain under arrangement, services for which an individual is entitled to under Medicare. Doing so discharges the liability of such individual or any other person to pay for the services. ...
July 13th, 2015
Claims Submitted for Items or Services Furnished to Medicare Beneficiaries in State or Local Custody Under a Penal Authority (Rev. 1944, Issued: 04-09-10)
By Find-A-Code | Published July 13th, 2015
Under Section 1862(a)(2) of the Social Security Act (“the Act”), the Medicare program does not pay for services if the beneficiary has no legal obligation to pay for the services and no other person or organization has a legal obligation to provide or pay for that service. Also, under Section ...
July 10th, 2015
Medicare Carrier or RRB-Named Carrier to Welfare Carrier (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 10th, 2015
When a Medicare carrier or RRB-named carrier receives a query reply from CMS that includes a disposition code 46 and a welfare administration carrier number, it transfers the claim to the welfare carrier and notifies the beneficiary. Any pertinent information received or developed is transferred with the claim.
This occurs only ...
July 10th, 2015
Protests Concerning Transfer of Requests for Payment to Carrier (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 10th, 2015
If Palmetto GBA receives a protest concerning the transfer of a request for Medicare payment to the carrier, the protest, including pertinent name and claim number(s) information, is forwarded to:
Railroad Retirement Board Medicare Section
844 Rush Street
Chicago, IL 60611
Pub 100-04 Medicare Claims Processing Manual
...
July 9th, 2015
Hospital Billing For Take-Home Drugs (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
All hospitals, including critical access hospitals (CAHs), bill the appropriate DME MAC for take-home supplies of oral anti-cancer drugs, oral anti-emetic drugs and multi-day supplies of immunosuppressive drugs, as well as the associated supplying fees. All inhalation drugs and the associated dispensing fees are also billed to the DME MAC.
Claims ...
July 9th, 2015
Payment Jurisdiction for Reassigned Services (Rev. 1987)
By Find-A-Code | Published July 9th, 2015
Though a supplier or provider may reassign payment for his services to another entity, suppliers are still required to bill the correct B/MAC for reassigned services when they are paid under the MPFS. The billing entity must submit claims to the B/MAC that has jurisdiction over the geographic area where ...
July 9th, 2015
Exceptions to Jurisdictional Payment (Rev. 1, 10-01-03)
By Find-A-Code | Published July 9th, 2015
Exceptions to billing the area carrier are:
• A claim for covered services performed in the United States by a legally authorized Canadian or Mexican physician is within the jurisdiction of the carrier servicing the location where the services were rendered.
• Because coverage of Part B services furnished in Canada or ...
July 9th, 2015
Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, Supplies, Parental and Enteral Nutrition (PEN) (Rev. 2487)
By Find-A-Code | Published July 9th, 2015
(Issued: 06-08-12, Effective: 01-01-11, Implementation: 06-19-12) B3-3116, B-3102
Claims for DMEPOS submitted by suppliers for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are handled by Durable Medical Equipment Medicare Administrative Contractors (DME MACs).
To determine which services are processed by DME MACs vs. local carriers, CMS maintains and updates a table ...
July 9th, 2015
Supplier of Portable X-Ray, EKG, or Similar Portable Services (Rev. 1, 10-01-03)
By Find-A-Code | Published July 9th, 2015
If a supplier operates mobile units in geographic areas served by more than one carrier, the carrier serving the area where the service was performed must process the claims.
Pub 100-04 Medicare Claims Processing Manual
...
July 9th, 2015
Ambulance Services Submitted to Carriers (Rev. 1, 10-01-03)
By Find-A-Code | Published July 9th, 2015
Jurisdiction of the claim is based on whether only one ambulance vehicle or multiple vehicles were used.
A. One Ambulance Vehicle Used
If only one vehicle is used to transport the patient from the point of initial pickup to the final destination, jurisdiction is with the carrier serving the point of ...
July 9th, 2015
Independent Laboratories (Rev. 1, 10-01-03)
By Find-A-Code | Published July 9th, 2015
Jurisdiction of claims for laboratory services furnished by an independent laboratory normally lies with the carrier serving the area in which the laboratory test is performed. However, there are some situations where a regional or national lab chain jurisdiction is with a single carrier.
Pub 100-04 Medicare Claims Processing Manual
...
July 9th, 2015
Laboratories Billing for Referred Tests (Rev. 85, 02-06-04)
By Jared Staheli | Published July 9th, 2015
Section 1833(h)(5)(A) of the Act provides that a referring laboratory may bill for clinical laboratory diagnostic tests on the clinical laboratory fee schedule for Medicare beneficiaries performed by a reference laboratory only if the referring laboratory meets certain conditions. Payment may be made to the referring laboratory but only if ...
July 9th, 2015
Claims Information and Claims Forms and Formats (Rev. 85, 02-06-04) - Billing for Clinical Laboratory Tests
By Jared Staheli | Published July 9th, 2015
Claims for referred laboratory services may be made only by suppliers having specialty code 69, i.e., independent clinical laboratories. Claims for referred laboratory services made by other entities will be returned as unprocessable.
Independent laboratories shall use modifier 90 to identify all referred laboratory services. A claim for a referred laboratory ...
July 9th, 2015
Paper Claim Submission to A/B MACs (B) (Rev. 3089, 01-01-15) - Billing for Clinical Laboratory Tests
By Jared Staheli | Published July 9th, 2015
An independent clinical laboratory may file a paper claim form shall file Form CMS- 1500 for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90.
An independent clinical laboratory that submits claims in paper format) may not combine non-referred ...
July 9th, 2015
Cases Involving Referral Laboratory Services (Rev. 1, 10-01-03)
By Find-A-Code | Published July 9th, 2015
If the specimen is drawn or received by an independent laboratory approved under the Medicare program that performs a covered test, but the lab refers the specimen to another laboratory in a different carrier jurisdiction for additional tests, the carrier servicing the referring laboratory retains jurisdiction for services performed by ...
July 9th, 2015
Electronic Claim Submission to A/B MACs (B) (Rev. 3089, 01-01-15) - Billing for Clinical Laboratory Tests
By Jared Staheli | Published July 9th, 2015
Electronic Claim Submission
SC X12 837 professional claim format (HIPAA compliant version):
CLIA number:
An electronic claim for laboratory testing will require the presence of the performing (and billing) laboratory’s CLIA number; if tests are referred to another laboratory, the CLIA number of the laboratory where the testing is rendered must also be ...
July 9th, 2015
Railroad Retirement Beneficiary Carrier (Rev. 142, 04-16-04)
By Find-A-Code | Published July 9th, 2015
Carrier jurisdiction claims for individuals who are QRRBs, including those who are entitled to both social security and railroad retirement benefits, are handled by the Palmetto Government Benefits Administrators (GBA) LLC, a subsidiary of Blue Cross and Blue Shield of South Carolina, with the following exceptions:
• The services are furnished ...
July 9th, 2015
Payment Limit for Purchased Services (Rev. 16, 10-31-03) - Billing for Clinical Laboratory Tests
By Jared Staheli | Published July 9th, 2015
For payment instructions for Physician purchased diagnostic tests refer to the Claims Processing Manual 100-04, Chapter 1, §30.2.9, Chapter 13 §20.2.4ff.
When an Independent Laboratory (IL) bills for the technical component (TC) of a physician pathology service purchased from a separate physician or supplier, the payment amount for the TC is ...
July 9th, 2015
Welfare Carriers (Rev. 1, 10-01-03)
By Find-A-Code | Published July 9th, 2015
Section 1843(f) of Title XVIII permits a State agency that administers a plan under Titles I, XVI, or XIX to become the carrier for individuals enrolled in the State’s Buy In agreement. Currently there are no State agencies that are serving as carriers.
Pub 100-04 Medicare Claims Processing Manual
...
July 9th, 2015
Hospital Billing Under Part B (Rev. 3014, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
Hospital laboratories, billing for either outpatient or non-patient claims, bill the A/B MAC (A).
Neither deductible nor coinsurance applies to laboratory tests paid under the fee schedule.
Hospitals must follow requirements for submission of the ASC X12 837 institutional claim or the hardcopy Form CMS-1450. (See Chapter 25 for a description of ...
July 9th, 2015
Critical Access Hospital (CAH) Outpatient Laboratory Service (Rev. 2971, 07-07-14)
By Jared Staheli | Published July 9th, 2015
Effective for services furnished on or after the enactment of the Balanced Budget Refinement Act of 1999 (BBRA), Medicare beneficiaries are not liable for any coinsurance, deductible, co-payment, or other cost sharing amount with respect to clinical laboratory services furnished as a CAH outpatient service. This change is effective for ...
July 9th, 2015
Special Skilled Nursing Facility (SNF) Billing Exceptions for Laboratory Tests (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
When a SNF furnishes laboratory services directly, it must have a Clinical Laboratory Improvement Act (CLIA) number or a CLIA certificate of waiver, and the laboratory itself must be in the portion of the facility so certified. Normally the FI makes payment under Part B for clinical laboratory tests only ...
July 9th, 2015
Disposition of Misdirected Claims to the B/MAC/Carrier/DME MAC (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
A “misdirected claim” is a claim that has been submitted to the wrong place. This section summarizes the disposition of misdirected claims by B MACs, carriers, and DME MACs.
Each fee-for-service claims administration contractor is assigned a specific geographic and subject matter jurisdiction for claims processing. Physicians and other suppliers are ...
July 9th, 2015
Which Contractor to Bill for Laboratory Services Furnished to a Medicare Beneficiary in a Skilled Nursing Facility (SNF) (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Inpatient Part A beneficiary - SNF bills the FI under Part A. The service is included in SNF PPS payment.
Inpatient Part B beneficiary (benefits exhausted or no Part A entitlement) - SNFs may provide the service and bill the FI, may obtain the service under arrangement and bill the ...
July 9th, 2015
Rural Health Clinic (RHC) Billing (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
For independent RHCs, laboratory services provided in the RHC’s laboratory are not included in the all-inclusive rate payment to the RHC and may be billed separately to the carrier. This includes the six basic laboratory tests required for certification as well as any other laboratory tests provided in the RHC ...
July 9th, 2015
A Local B/MAC/Carrier Receives a Claim for Services that are in Another Local B/MAC/Carrier’s Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier) receives a CMS-1500 or electronic claim for Medicare payment for items/services furnished outside of its payment jurisdiction, the claim shall be returned as unprocessable.
NOTE: This instruction also applies to claims for DMEPOS items/services that are appropriately billed to the B MAC/carrier, ...
July 9th, 2015
Billing for End Stage Renal Disease (ESRD) Related Laboratory Tests (Rev. 2487, 06-19-12)
By Jared Staheli | Published July 9th, 2015
With the implementation of the ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD-related laboratory services are included in the ESRD PPS base rate and must be reported by the ESRD facility and are not separately paid. For instructions on ESRD facility ...
July 9th, 2015
A Local B/MAC/Carrier Receives a Claim for Services that are in A DME MAC’s Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier) receives a CMS-1500 or electronic claim for Medicare payment for items/services that are in a DME MAC’s payment jurisdiction, the claim shall be returned as unprocessable.
Use the following messages for claims indicated above except for claims that are identified as UMWA ...
July 9th, 2015
A DME MAC Receives a Claim for Services that are in A Local B/MAC/Carrier’s Payment Jurisdiction (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
When a local DME MAC receives a CMS-1500 or electronic claim for Medicare payment for items/services that are in a Part B MAC or carrier’s payment jurisdiction, the claim shall be returned as unprocessable.
Use the following messages for claims indicated above except for claims that are identified as UMWA claims:
CARC ...
July 9th, 2015
A Local B/MAC/Carrier Receives a Claim for an RRB Beneficiary (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier) receives a Form CMS-1500 or electronic claim that is identified as a RRB claim for Medicare payment that should be processed by the RRB contractor, the claim shall be returned as unprocessable. Use the following messages:
CARC 109 – Claim not covered ...
July 9th, 2015
A Local B/MAC/Carrier/DME MAC Receives a Claim for a UMWA Beneficiary (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 9th, 2015
When a local contractor (Part B MAC or carrier/DME MAC) receives a Form CMS-1500 or electronic claim that is identified as a UMWA claim for Medicare payment that should be processed by the UMWA, the claim shall be returned as unprocessable.
Use the following messages:
CARC 109 - Claim not covered by ...
July 9th, 2015
Claims Processing for Separately Billable Tests for ESRD Beneficiaries (Rev. 1655, 02-02-09)
By Jared Staheli | Published July 9th, 2015
Clinical laboratory tests can be performed individually or in predetermined groups on automated profile equipment. If a test profile is performed see §40.6.1. If a clinical laboratory test is performed individually, see §40.6.2.1. However the tests are performed in the laboratory setting, the services must be billed individually, and must ...
July 9th, 2015
Separately Billable ESRD Laboratory Tests Furnished by Hospital-Based Facilities (Rev. 1655, 02-02-09)
By Jared Staheli | Published July 9th, 2015
Independent laboratories and independent dialysis facilities with the appropriate clinical laboratory certification in accordance with CLIA may be paid for ESRD clinical laboratory tests that are separately billable. The laboratories and independent dialysis facilities are paid for separately billable clinical laboratory tests according to the Medicare laboratory fee schedule for ...
July 9th, 2015
Skilled Nursing Facility (SNF) Consolidated Billing (CB) Editing and Separately Billed ESRD Laboratory Test Furnished to Patients of Renal Dialysis Facilities (Rev. 1769, 07-31-09)
By Jared Staheli | Published July 9th, 2015
Effective April 1, 2003, for DOS on or after April 1, 2001, CWF will not apply the SNF CB edits to line items that contain the CB modifier. A provider or supplier may use the “CB” modifier only when it has determined that: (a) the beneficiary has ESRD entitlement, (b) ...
July 9th, 2015
Billing for Noncovered Clinical Laboratory Tests (Rev. 1, 10-01-03)
By Jared Staheli | Published July 9th, 2015
Ordinarily, neither a physician nor a laboratory bills the Medicare Program for noncovered tests. However, if the beneficiary (or his/her representative) contends that a clinical laboratory test which a physician or laboratory believes is noncovered may be covered, the physician or laboratory must file a claim that includes the test ...
July 9th, 2015
Billing for Hemophilia Clotting Factors (Rev. 1564, 01-05-09)
By Jared Staheli | Published July 9th, 2015
Blood clotting factors not paid on a cost or prospective payment system basis are priced as a drug/biological under the drug pricing fee schedule effective for the specific date of service. As of January 1, 2005, the average sales price (ASP) plus 6 percent shall be used.
If a beneficiary is ...
July 9th, 2015
Hospitals Billing for Epoetin Alfa (EPO) and Darbepoetin Alfa (Aranesp) for Non-ESRD Patients (Rev. 1412, 04-07-08)
By Jared Staheli | Published July 9th, 2015
NOTE: For EPO and Aranesp billing instructions for beneficiaries with ESRD, see the Claims Processing Manual, Chapter 8, sections 60.4 and 60.7.
For patients with chronic renal failure who are not yet on a regular course of dialysis, EPO and Aranesp administered in a hospital and billed as an outpatient service ...
July 9th, 2015
Claims Processing Rules for Hospital Outpatient Billing and Payment - Drugs, Biologicals, and Radiopharmaceuticals (Rev. 2903, 04-07-14)
By Jared Staheli | Published July 9th, 2015
A. General Billing and Coding for Hospital Outpatient Drugs, Biologicals, and Radiopharmaceuticals
Hospitals should report charges for all drugs, biologicals, and radiopharmaceuticals, regardless of whether the items are paid separately or packaged, using the correct HCPCS codes for the items used. It is also of great importance that hospitals billing ...
July 8th, 2015
Billing Drugs Electronically - NCPDP (Rev. 3085, Implementation: Upon Implementation of ICD-10)
By Jared Staheli | Published July 8th, 2015
The National Council for Prescription Drug Programs (NCPDP) Telecommunications Standard Version D.0 and Batch Standard 1.2 is the HIPAA standard for electronic retail pharmacy drug claims and coordination of benefits (COB). See the NCPDP web site at http://www.ncpdp.org for additional information.
DME MACs that process retail pharmacy drug transactions require their ...
July 8th, 2015
Billing and Payment Instructions for A/B MACs (A) (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 8th, 2015
Claims for the oral anti-emetic drug aprepitant, either as a 3-day supply dispensed in a Tri-Pak or as the first day supply (not dispensed in a Tri-Pak), must be billed to the A/B MAC (A) on the ASC 837 institutional claim format or on hard copy Form CMS-1450 with the ...
July 8th, 2015
Billing for Immunosuppressive Drugs (Rev. 1448; 07-07-08)
By Jared Staheli | Published July 8th, 2015
Beginning January 1, 1987, Medicare pays for FDA approved immunosuppressive drugs and for drugs used in immunosuppressive therapy. (See the Medicare Benefit Policy Manual, Chapter 15 for detailed coverage requirements.) Generally, contractors pay for self-administered immunosuppressive drugs that are specifically labeled and approved for marketing as such by the FDA, ...
July 8th, 2015
Requirements for Billing A/B MAC (A) for Immunosuppressive Drugs (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 8th, 2015
Hospitals not subject to OPPS bill on ASC X12 837 institutional format or paper Form CMS-1450 (if approved) with bill type 12x (hospital inpatient Part B) or l3x (hospital outpatient) as appropriate.
For claims with dates of service prior to April 1, 2000, providers report the following entries:
• Occurrence code 36 ...
July 7th, 2015
Professional Billing Requirements for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11,
By Jared Staheli | Published July 7th, 2015 - Last Review/Update February 5th, 2018
For claims with dates of service on and after October 14, 2011, CMS will allow coverage for annual alcohol misuse screening, 15 minutes, G0442, and behavioral counseling for alcohol misuse, 15 minutes, G0443, only when services are submitted by the following provider specialties found on the provider’s enrollment record:
01 - ...
July 7th, 2015
Professional Billing Requirements for Screening for Depression in Adults (Rev. 2431, 10-14-11)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the following claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare Summary Notice (MSN) messages when denying payment for G0444 when reported more than once in a 12- month period.
o CARC 119 – “Benefit maximum for this time period or occurrence has ...
July 7th, 2015
Institutional Billing Requirements for Screening for Depression in Adults (Rev. 2431, 10-14-11)
By Jared Staheli | Published July 7th, 2015
For claims with dates of service on and after October 14, 2011, Medicare will allow coverage for annual screening depression in adults, HCPCS G0444 for:
• Rural Health Clinics (RHCs) type of bill (TOB) 71X only – based on the all-inclusive payment rate.
• Federally Qualified Health Centers (FQHCs) TOB 77X only ...
July 7th, 2015
Professional Billing Requirements for Policy for Intensive Behavioral Therapy for Obesity (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
CMS will allow coverage for Face-to-Face Behavioral Counseling for Obesity, 15 minutes, (G0447), Face-to-face behavioral counseling for obesity, group (2-10), 30 minute(s) (G0473), along with 1 of the ICD-9 codes for BMI 30.0-BMI 70 (V85.30- V85.39 and V85.41-V85.45), only when services are submitted by the following provider specialties found on ...
July 7th, 2015
Institutional Billing Requirements for Screening for Hepatitis C Virus (HCV) (Rev. 3215, 01-05-15)
By Jared Staheli | Published July 7th, 2015
Effective for claims with dates of service on and after June 2, 2014, providers may use the following types of bill (TOBs) when submitting claims for screening for HCV screening, HCPCS G0472: 13X, 71X, 77X, and 85X. Service line-items on other TOBs shall be denied.
The service shall be paid on ...
July 7th, 2015
Professional Billing Requirements for Screening for Hepatitis C Virus (HCV) (Rev. 3215, 01-05-15)
By Jared Staheli | Published July 7th, 2015
For claims with dates of service on or after June 2, 2014, Medicare will allow coverage for HCV screening, HCPCS G0472, only when services are ordered by the following provider specialties found on the provider’s enrollment record:
01 - General Practice
08 - Family Practice
11 - Internal Medicine
16 - Obstetrics/Gynecology
37 - Pediatric ...
July 6th, 2015
A/B MAC and Fiscal Intermediary (FI) Billing Requirements for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Contractors will pay for IPPE or EKG only when the services are submitted on one of the following TOBs: 12X, 13X, 22X, 71X, 73X and 85X.
Type of facility and setting determines the basis of payment:
• For the IPPE or the screening EKG tracing only performed on a 12X and 13X ...
July 6th, 2015
Carrier Billing Requirements for Diabetes Screening (Rev. 457, 04-04-05)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service January 1, 2005 and later, carriers shall recognize the above HCPCS codes for diabetes screening.
Carriers shall pay for diabetes screening once every 12 months for a beneficiary that is not pre-diabetic. Carriers shall pay for diabetes screening at a frequency of once every 6 months ...
July 6th, 2015
Special Processing Instructions for Billing Frequency Requirements of DSMT Services (Rev. 1255, 07-02-07)
By Jared Staheli | Published July 6th, 2015
The frequency editing for DSMT is performed in CWF as follows:
A - Initial Training
The initial year for DSMT is the '12' month period following the initial date. When a claim contains a DSMT HCPCS code and the associated units cause the total time for the DSMT initial year to exceed ...
July 6th, 2015
Billing Requirements for HIV Screening Tests (Rev. 2199, 07-06-10)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service December 8, 2009, and later, contractors shall recognize the above HCPCS codes for HIV screening.
Medicare contractors shall pay for voluntary HIV screening as follows in accordance with Pub. 100-03, Medicare National Coverage Determinations Manual, sections 190.14 and 210.7:
• A maximum of once annually for beneficiaries ...
July 6th, 2015
A/B MAC and Fiscal Intermediary (FI) Billing Requirements for the AWV (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
The FI will pay for AWV services only when submitted on one of the following types of bill (TOBs): 12X, 13X, 22X, 23X, 71X, 77X, and 85X. Type of facility and setting determines the basis of payment:
• For services performed on a 12X TOB and 13X TOB, hospital inpatient Part ...
July 6th, 2015
Billing Requirements for Screening for STIs and HIBC to Prevent STIs (Rev. 2476, 02-27-12)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service November 8, 2011, and later, contractors shall recognize HCPCS code G0445 for HIBC. Medicare shall cover up to two occurrences of G0445 when billed for HIBC to prevent STIs. A claim that is submitted with HCPCS code G0445 for HIBC shall be submitted with ICD-9 ...
June 30th, 2015
Payment Jurisdiction for Services Subject to the Anti-Markup Payment Limitation
By Find-A-Code | Published June 30th, 2015
(Rev. 3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming April 1, 2015 - For Testing and Implementation; Implementation January 5, 2015, April 6, 2015 – For MAC testing of PECOS changes only)
Diagnostic tests and their interpretations are paid on the MPFS. Therefore, they are ...
June 29th, 2015
Type of Bill and Revenue Codes for Form CMS-1450 for Screening Pap Smears (Rev. 827, 07-03- 06)
By Jared Staheli | Published June 29th, 2015
The applicable bill types for screening Pap smears are 12X, 13X, 14X, 22X, 23X, and 85X. Use revenue code 0311 (laboratory, pathology, cytology). Report the screening pap smear as a diagnostic clinical laboratory service using one of the HCPCS codes shown in §30.5.B.
In addition, CAHs electing method II report professional ...
June 29th, 2015
HIPAA Standards for Claims
By Find-A-Code | Published June 29th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014) The standards adopted under HIPAA include both a transaction standard and an implementation guide. The following are the claims transactions and the implementation ...
June 29th, 2015
Payment Method for Screening Pelvic Examinations (Rev 440, 07-05-05)
By Jared Staheli | Published June 29th, 2015
Pelvic examinations are paid under the MPFS, whether billed to the FI or carrier except:
• Hospital outpatient services are paid under OPPS;
• See §40.5.B of this chapter for proper billing by RHC/FQHCs for the professional and technical components of a screening pelvic examination. RHCs/FQHCs are paid under the all-inclusive rate ...
June 29th, 2015
Claims Processing Instructions for Payment Jurisdiction
By Find-A-Code | Published June 29th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014)
A. Instructions for the 4010/4010A1 Version of the ASC X12 837 Professional Electronic Claim (for Claims Processed Before Implementation of Version 5010)
Note that ...
June 29th, 2015
Revenue Code and HCPCS Codes for Billing for Screening Pelvic Examinations (Rev. 827, 07-03- 06)
By Jared Staheli | Published June 29th, 2015
A. Billing to the Carrier
Code G0101 (cervical or vaginal cancer screening, pelvic and clinical breast examination) is used.
Effective for services on or after January 1, 1999, a covered evaluation and management (E/M) visit and code G0101 may be reported by the same physician for the same date of service ...
June 26th, 2015
Billing Requirements – Carrier/B MAC Claims (Rev. 1931, 06-14-10)
By Jared Staheli | Published June 26th, 2015
Contractors use the weekly-updated file to verify that the billing facility is certified by the FDA to perform mammography services, and has the appropriate certification to perform the type of mammogram billed (film and/or digital). Carriers/B MACs match the FDA assigned, 6-digit mammography certification number on the claim to the ...
June 26th, 2015
Transportation Costs for Mobile Units (Rev. 1, 10-01-03)
By Jared Staheli | Published June 26th, 2015
Transportation costs are associated with mobile units for diagnostic mammography tests only. CMS formally added diagnostic mammography to the regulation language of the portable x-ray benefit in 42 CFR 410.32(c)(3). These units are usually reserved for screening tests only. For the screening tests performed in a mobile unit, there is ...
June 25th, 2015
Billing Requirements (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
A. Edits Not Applicable to Pneumococcal or Influenza Virus Vaccine Bills and Their Administration
The Common Working File (CWF) and shared systems bypass all Medicare Secondary Payer (MSP) utilization edits in CWF on all claims when the only service provided is pneumococcal or influenza virus vaccine and/or their administration. This ...
June 25th, 2015
Bills Submitted to FIs/AB MACs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The applicable types of bills acceptable when billing for influenza virus and pneumococcal vaccines are 12X, 13X, 22X, 23X, 34X, 72X, 75X, 83X and 85X.
The following revenue codes are used for reporting vaccines and administration of the vaccines for all providers except RHCs and FQHCs. Independent and provider based RHCs ...
June 25th, 2015
Bills Submitted to Regional Home Health Intermediaries (RHHIs) (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The following provides billing instructions for Home Health Agency (HHAs) in various situations:
• Where the sole purpose for an HHA visit is to administer a vaccine (influenza virus, pneumococcal, or hepatitis B), Medicare will not pay for a skilled nursing visit by an HHA nurse under the HHA benefit. However, ...
June 25th, 2015
Bills Submitted by Hospices and Payment Procedures for Renal Dialysis Facilities (RDF) (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Hospices can provide the influenza virus, pneumococcal, and hepatitis B vaccines to those beneficiaries who request them including those who have elected the hospice benefit. These services may be covered when furnished by the hospice. Services for the vaccines should be billed to the local carrier/AB MAC on the Form ...
June 25th, 2015
Hepatitis B Vaccine Furnished to ESRD Patients (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
Hepatitis B vaccine and its administration (including staff time and supplies such as syringes) are paid to ESRD facilities in addition to, and separately from, the dialysis composite rate payment.
Payment for the hepatitis B vaccine for ESRD patients follows the same general principles that are applicable to any injectable drug ...
June 25th, 2015
Centralized Billing for Influenza Virus and Pneumococcal Vaccines to Medicare Carriers/AB MACs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The CMS currently authorizes a limited number of providers to centrally bill for influenza virus and pneumococcal immunization claims. Centralized billing is an optional program available to providers who qualify to enroll with Medicare as the provider type “Mass Immunization Roster Biller,” as well as to other individuals and entities ...
June 25th, 2015
Simplified Billing for Influenza Virus and Pneumococcal Vaccine Services by HHAs (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The following billing instructions apply to HHAs that roster bill for influenza virus and pneumococcal vaccines.
• When an HHA provides the influenza virus vaccine or the pneumococcal vaccine in a mass immunization setting, it does not have the option to pick and choose whom to bill for this service. If ...
June 25th, 2015
Hospital Inpatient Roster Billing (Rev. 1586, 10-06-08)
By Jared Staheli | Published June 25th, 2015
The following billing instructions apply to hospitals that roster bill for the influenza virus vaccine and the pneumococcal vaccine provided to inpatients:
• Hospitals do not have to wait until patients are discharged to provide the vaccine. They may provide it anytime during the patient’s stay;
• The roster should reflect the ...
June 25th, 2015
CAD Billing Charts (Rev. 1070, 01-02-07)
By Jared Staheli | Published June 25th, 2015
The following chart provides guidance for billing of CAD add-on codes. It reflects appropriate coding combinations that may be billed and the time frames associated with each.
Chart I – Screening CAD Codes
CAD Codes
Effective 01-01-02 thru 03-31-03
Effective 04-01-03 thru 12-31-03
Effective 01-01-04 thru 12-31-06
Effective 01-01-07 and later
76085
76092
76092, G0202
N/A
N/A
76083
N/A
N/A
76092, G0202
N/A
77052
N/A
N/A
N/A
77057, G0202
Chart II – ...
June 25th, 2015
Mobile Units for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
The entity providing the service must bill for the service unless the service is provided under contractual arrangements. If the contracted entity performs services on space that the IHS facility owns or leases, the IHS facility can bill under arrangements.
In order to purchase a professional test interpretation, the IHS physician ...
June 25th, 2015
Mobile Mammography Units for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
With respect to mobile mammography units, the law provides specific standards regarding those qualified to perform mammograms and how they should be certified. The Mammography Quality Standards Act (MQSA) requires the Secretary to ensure that all facilities that provide mammography services meet national quality standards. Effective October 1, 1994, all ...
June 25th, 2015
Services Billed to the DME MAC for Indian Health Services (Rev. 1040, 09-11-06)
By Jared Staheli | Published June 25th, 2015
Effective July 1, 2005, IHS suppliers and IHS providers (including CAHs) shall bill the appropriate DME MAC for DME.
Although, parenteral and enteral nutrients, equipment, and supplies meet the definition of the prosthetic benefit, they are separately billable to the DME MAC for home use. Ostomy, tracheostomy, and urological supplies meet ...
June 25th, 2015
Prosthetics, Orthotics and Supplies Billed to the A/B MAC for Indian Health Services (Rev. 1957; 10- 04-10)
By Jared Staheli | Published June 25th, 2015
Effective for dates of service on or after July 1, 2005, IHS providers, including CAHs shall bill the designated A/B MAC for prosthetics and orthotics under revenue code 0274 (prosthetic/orthotic devices) on type of bill (TOB) 12X (hospital inpatient part B), 13X (hospital outpatient) or 85X (Critical Access Hospital (CAH). ...
June 22nd, 2015
Chiropractic Policy Addendum: Maintenance Therapy CR2717
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 22nd, 2015 - Last Review/Update August 7th, 2017
The Centers for Medicare & Medicaid Services (CMS) has further defined Chiropractic Maintenance Therapy. Section 2251.3 of the Medicare Carriers Manual (MCM) has been amended to clarify Medicare requirements for treatment of chiropractic therapy.
"MCM 2251.3 Necessity for Treatment.--
A. The patient must have a significant health problem in the form of a neuromusculoskeletal ...
June 18th, 2015
DME MACs – Billing Procedures Related To Advanced Beneficiary Notice (ABN) Upgrades (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
This section provides the DME MACs billing instructions regarding the use of ABNs and claims modifiers for upgrades for items of DMEPOS.
Federal Regulations at 42 CFR 411.408 and Chapter 30 of this manual establishes the basis for a supplier to issue an ABN to a beneficiary. The purpose of the ...
June 18th, 2015
Providing Upgrades of DMEPOS Without Any Extra Charge (Rev. 2993, Upon Implementation of ICD-10)
By Jared Staheli | Published June 18th, 2015
Instead of using ABNs and charging beneficiaries for upgraded items, suppliers in certain circumstances may decide to furnish beneficiaries with upgraded equipment but charge the Medicare program and the beneficiary the same price they would charge for a nonupgraded item. The reason for this may be that a supplier prefers ...
June 18th, 2015
Provider Billing for Prosthetic and Orthotic Devices (Rev. 2629, 02-05-13)
By Jared Staheli | Published June 18th, 2015
See § 01 for definition of provider.
These items consist of all prosthetic and orthotic devices excluding parenteral/enteral nutritional supplies and equipment and intraocular lenses.
Prosthetics and orthotic devices are included in the Part A PPS rate unless specified as being outside the rate. For SNFs, customized prosthetic devices that are not ...
June 18th, 2015
Billing for Inexpensive or Other Routinely Purchased DME (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
This is equipment with a purchase price not exceeding $150, or equipment that the Secretary determines is acquired by purchase at least 75 percent of the time, or equipment that is an accessory used in conjunction with a nebulizer, aspirator, or ventilators that are either continuous airway pressure devices or ...
June 18th, 2015
Billing for Items Requiring Frequent and Substantial Servicing (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
These are items such as intermittent positive pressure breathing (IPPB) machines and ventilators, excluding ventilators that are either continuous airway pressure devices or intermittent assist devices with continuous airway pressure devices.
Suppliers and providers other than HHAs bill the DMERC. HHAs bill the RHHI.
...
June 18th, 2015
Billing for Certain Customized Items (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Due to their unique nature (custom fabrication, etc.), certain customized DME cannot be grouped together for profiling purposes. Claims for customized items that do not have specific HCPCS codes are coded as E1399 (miscellaneous DME). This includes circumstances where an item that has a HCPCS code is modified to the ...
June 18th, 2015
Billing for Capped Rental Items (Other Items of DME) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
These are DME items, other than oxygen and oxygen equipment, not covered by the above categories. Suppliers and providers other than HHAs bill the DMERC. HHAs bill the RHHIs.
...
June 18th, 2015
Billing for Oxygen and Oxygen Equipment (Rev. 1493; 04- 07-08)
By Jared Staheli | Published June 18th, 2015
The following instructions apply to all claims from providers and suppliers to whom payment may be made for oxygen. The chart in §130.6.1 indicates what is payable under which situation.
...
June 18th, 2015
Oxygen Equipment and Contents Billing Chart (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
The following chart indicates what oxygen fee schedule component is billable/payable under various transaction scenarios for providers and suppliers:
1. Situation: Beneficiary Uses a Stationary System Only
a. Rental Cases (Beneficiary Uses a Stationary System Only)
Type of System
Stationary Monthly Payment
Oxygen Content Fee
Portable Add-On
Portable Contents Fee
Concentrator
Yes
No
No
No
E1377 E1378 E1379 E1380 E1381 E1382 E1383 E1384 ...
June 18th, 2015
Billing for Maintenance and Servicing (Providers and Suppliers) (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
General
Payment is not made for maintenance and servicing if the beneficiary rents the equipment since payment for maintenance and servicing are included in the rental payments. An exception to this is the 6-month service fee for capped rental items that the beneficiary has elected not to purchase (see §40.2 and ...
June 18th, 2015
Billing for Supplies and Drugs Related to the Effective Use of DME (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
Suppliers and providers bill supplies that are necessary for the effective use of DME, including drugs, with the appropriate HCPCS code identifying the supply. HHAs must also report revenue code 0294, "Supplies/Drugs for DME Effectiveness."
Suppliers and providers, other than HHAs, bill supplies and drugs (not including drugs that are necessary ...
June 18th, 2015
Billing for HHA Medical Supplies (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Medical supplies are items that, due to their therapeutic or diagnostic characteristics, are essential in enabling personnel to carry out effectively the care the physician has ordered for the treatment or diagnosis of the patient's illness or injury. Medical supplies fit into two categories. They are classified as:
• Routine because ...
June 18th, 2015
Billing for Total Parenteral Nutrition and Enteral Nutrition (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
All providers and suppliers billing for parenteral and enteral nutrition covered as a Part B prosthetic device benefit bill the DMERCs. Medicare pays for no more than a one-month supply of parenteral or enteral nutrients for any one prospective billing period. Claims submitted retroactively may include multiple months.
...
June 18th, 2015
Billing for Total Parenteral Nutrition and Enteral Nutrition Furnished to Part B Inpatients (Rev. 2993, Upon Implementation of ICD-10)
By Jared Staheli | Published June 18th, 2015
Inpatient Part A hospital or SNF care includes total parenteral nutrition (TPN) systems and enteral nutrition (EN).
For inpatients for whom Part A benefits are not payable (e.g., benefits are exhausted or the beneficiary is entitled to Part B only), total parenteral nutrition (TPN) systems and enteral nutrition (EN) delivery systems ...
June 18th, 2015
Special Considerations for SNF Billing for TPN and EN Under Part B (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
The HCPCS code and any appropriate modifiers are required. SNFs bill the A/B MAC (B) for TPN and EN under Part B, using the ASC X12 837 professional claim format, or the Form CMS-1500 paper claim if applicable.
The following HCPCS codes apply.
B4034 B4035 B4036 B4081 B4082 B4083 B4084 B4085 B4150 ...
June 18th, 2015
Billing for Splints and Casts (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
The cost of supplies used in creating casts are not included in the payment amounts for the CPT codes for fracture management and for casts and splints. Thus, for settings in which CPT codes are used to pay for services that include the provision of a cast or splint, supplies ...
June 18th, 2015
SNF Consolidated Billing and DME Provided by DMEPOS Suppliers (Rev. 222, 07-02-04)
By Jared Staheli | Published June 18th, 2015
The Social Security Act (§1861(n)) specifies that a hospital or a skilled nursing facility (SNF) cannot be considered a patient’s “home” for purposes of the DME benefit. (This restriction of coverage to only those items that are furnished for use in the patient’s home does not apply to coverage under ...
June 18th, 2015
Home Health Consolidated Billing and Supplies Provided by DMEPOS Suppliers (Rev. 2977, Upon Implementation of ICD-10)
By Jared Staheli | Published June 18th, 2015
Section 1842 (b)(6)(F) of the Social Security Act requires consolidated billing of all home health services while a beneficiary is under a home health plan of care authorized by a physician. Consequently, Medicare makes payment for all such items and services to a single home health agency (HHA) overseeing that ...
June 15th, 2015
General Inpatient Requirements (Rev. 1, 10-01-03)
By Find-A-Code | Published June 15th, 2015
HO-400, HO-400.G, HO-403, HO-412
The hospital may bill only for services provided. If the provider billing system initiates billing based on services ordered, the provider must confirm that the service has been provided before billing either the carrier or intermediary (FI).
The provider agreement to participate in the program requires the provider ...
June 15th, 2015
Carrier Jurisdiction of Requests for Payment (Rev. 2487)
By Find-A-Code | Published June 15th, 2015
Carriers have jurisdiction for all claims from the following:
• Physicians;
• Other individual practitioners;
• Groups of physicians or practitioners;
• Labs not part of a hospital;
• Ambulance claims submitted by ambulance companies under their own Medicare number (hospitals may operate ambulances as part of the hospital and bill the intermediary (FI));
• Ambulatory ...
May 11th, 2015
Modifier 33
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 11th, 2015 - Last Review/Update January 30th, 2017
Modifier 33 for Preventive Care
With the implementation of modifier 33 and its complicated and unique description, many coders have wondered how to properly apply it. Let's review the information we have on the modifier and see if we can better understand how and when to use it.
Modifier 33 was created ...
April 23rd, 2015
Alcohol Screening to Reduce Misuse
By Wyn Staheli, Director of Research | Published April 23rd, 2015 - Last Review/Update June 9th, 2016
April is Alcohol Awareness Month and April 9 is National Alcohol Screening Day. Because alcohol misuse contributes to a variety of both social and medical problems, this day was set aside as a way to reach out, educate and increase awareness in communities. By screenings and other initiatives, at-risk individuals ...
April 15th, 2015
Medicare Updates Preventive Exam and Wellness Visit Information
By Wyn Staheli, Director of Research | Published April 15th, 2015 - Last Review/Update June 9th, 2016
Medicare has updated their provider educational tools for the Initial Preventive Physical Examination (IPPE) and the Annual Wellness Visit (AWV). These tools were designed to help providers gain a greater understanding of these services. Learn what the required elements for these services as well as important coverage and coding information.
CLICK ...
March 17th, 2015
Patient Information Form
By Raquel Shumway | Published March 17th, 2015 - Last Review/Update June 9th, 2016
We have two different samples for Patient Information Forms. We suggest that you review both and determine which best fits your practice model. Form #2 is editable so it could be easily modified for your organization. Both forms provide the basic information necessary for all types of healthcare practices.
Instructions for: Patient ...
March 9th, 2015
Billing Imminuzation for Pneumococcal, Influenza, and Hepatitis B with Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 9th, 2015 - Last Review/Update August 9th, 2017
The current diagnosis pointer for, Influenza, Pneumococcal or Hepatitis B vaccines is ICD-10-CM code Z23. Listed are tips for coding, and also the diagnosis pointers used for claims previous to 10/01/15:
Influenza: G0008
Procedure codes:
90630
90653-90662
90672-90674
90685-90688
Medicare codes:
Q2034-Q2039
Expired diagnosis code:
V04.81
Pneumococcal: G0009
Procedure codes:
90670
90732
Expired diagnosis code:
V03.82
Hepatitis B: G0010
Procedure codes
90739-90747
Expired diagnosis code
V05.3
Both Influenza and Pneumococcal Vaccines received in same visit: G0008 with G0009
Procedure codes:
(See previous)
Expired diagnosis code:
V06.6 (effective 10/01/06 - 09/30/15)
Extra Tips:
Be sure ...
March 6th, 2015
Antipsychotic Drug use and Patient Care
By Wyn Staheli, Director of Research | Published March 6th, 2015 - Last Review/Update February 18th, 2016
In an effort to improve quality of care in nursing home, CMS has been reviewing PQRS quality measures and offering provider training through a variety of mediums. Antipsychotic drug use is just one of the measures being reviewed. The MLN Connects Provider eNews for February 12, 2015 included the following notice about ...
February 26th, 2015
Chiropractic Billing 101: A Basic Guide
By | Published February 26th, 2015 - Last Review/Update January 27th, 2017
Director of Communications, ChiroCode
In my 20 years of professional bull riding I have had many highs and lows. There were times when the rankest of bulls couldn’t throw me and times when I couldn’t ride a rocking chair. When in a slump, what always worked for me, and for the ...
February 23rd, 2015
Q & A: Why is Medicare Denying Claims?
By | Published February 23rd, 2015 - Last Review/Update March 9th, 2016
Q: We have recently enrolled with Medicare and treat only a few patients. However, those claims are being denied. Can you help me to understand why this might be happening?
A: First, I would recommend you carefully review your Medicare Remittance Advice as that will identify the reason Medicare is denying your ...
February 23rd, 2015
Global Surgery Fact Sheet
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 23rd, 2015 - Last Review/Update February 16th, 2016
The global surgical package, also called global surgery, includes all necessary services normally
furnished by a surgeon before, during, and after a procedure. Medicare payment for the surgical
procedure includes the pre-operative, intra-operative and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. ...
February 21st, 2015
Billing Requirements for G0466, G0467, G0468, G0469 or G0470 - MLN
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 21st, 2015 - Last Review/Update February 18th, 2016
Basic Billing Requirements
When reporting an encounter/visit for payment, the claim (77X TOB) must contain a FQHC specific payment code (G0466, G0467, G0468, G0469 or G0470) that corresponds to the type of visit.
FQHC specific payment specific codes G0466, G0467 and G0468 must be reported under revenue code 052X or under ...
February 15th, 2015
Underdosing - a New Clinical Concept in ICD-10 codes T36 – T50
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 15th, 2015 - Last Review/Update March 1st, 2016
T36-T50 Poisoning by, adverse effects of and underdosing of drugs, medicaments and biological substances (T36-T50)
Underdosing is a clinical concept new to ICD-10. Underdosing identifies situations referring to the practice of a patient taking less medication as prescribed by a physician, or a physician prescribing less than what is prescribed by ...
February 15th, 2015
CMS Opt-Out Regulations and Guidelines
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 15th, 2015 - Last Review/Update March 1st, 2016
40-Effect of Beneficiary Agreements Not to Use Medicare Coverage
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
(Rev. 194, 09-03-14)
Normally physicians and practitioners are required to submit claims on behalf of beneficiaries for all items and services they provide for which Medicare payment may be made under Part B. Also, they are ...
February 9th, 2015
Coding And Billing For JETREA - Physician Office
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 9th, 2015 - Last Review/Update August 9th, 2017
The information contained below is provided for informational purposes only and is not intended to provide specific guidance on how to code, bill, or charge for any product or service. The following list provides possible codes that may relate to the use of JETREA for its approved indication and is ...
February 9th, 2015
Coding And Billing For JETREA® - Hospital Outpatient Department
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 9th, 2015 - Last Review/Update August 9th, 2017
The information contained below is provided for informational purposes only and is not intended to provide specific guidance on how to code, bill, or charge for any product or service. The following list provides possible codes that may relate to the use of JETREA for its approved indication and is ...
February 4th, 2015
Virtual Cards
By Wyn Staheli | Published February 4th, 2015 - Last Review/Update June 9th, 2016
Sometimes called "disposable," "temporary," or "one-time use" numbers, a virtual credit card number is "like putting a wall" between your transaction and your regular account, says Steve Kenneally, vice president of the American Bankers Association. Although these cards can protect the cardholder from fraud, the use of virtual cards as ...
January 28th, 2015
Modifier XE Fact Sheet
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 28th, 2015 - Last Review/Update August 9th, 2017
Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
Coding pairs are part of the National Correct Coding Initiative (NCCI) procedure to procedure edits
Documentation indicates the services were provided during separate patient/provider encounter
Use Modifier XE with the Column 2 procedure code in the NCCI files
Use Modifier XE only when there ...
January 16th, 2015
Billing for Split Unit of Blood
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 16th, 2015 - Last Review/Update March 1st, 2016
Billing for Split Unit of Blood
(Rev. 1487, Issued: 04-08-08, Effective: 04-01-08, implementation: 04-07-08)
HCPCS code P9011 was created to identify situations where one unit of blood or a blood product is split, and some portion of the unit is transfused to one patient while the other portions are transfused to other patients ...
January 9th, 2015
How Important is Your Fee Schedule?
By | Published January 9th, 2015 - Last Review/Update June 13th, 2016
Did you know that inconsistent and un-reviewed fee schedules can lead to some of the following occurrences:
• Prompt an audit or some level of claims review
• Cause claims delays
• Increase provider liability in case of an audit or investigation
• Potentially lead to being paid less than the actual value of ...
January 8th, 2015
Discounts by ChiroCode
By ChiroCode | Published January 8th, 2015 - Last Review/Update January 30th, 2017
All healthcare providers need to be aware that there are both appropriate and inappropriate ways to discount your fees. Both state and federal laws can impact your practice financial policy regarding fee discounts. Additionally, we recommend carefully reviewing Section F-Fees of the ChiroCode DeskBook for important information on fee schedules and ...
December 30th, 2014
Understanding TOS Discounts and DMPOs
By | Published December 30th, 2014 - Last Review/Update March 9th, 2016
Time-of-Service (TOS) discounts are a common occurrence in chiropractic. What is often assumed is that if insurance isn't involved, there are no rules that apply.
Unfortunately, this is a myth that can become costly to practices and damage provider/patient relationships. So read on to learn the facts about TOS discounting and ...
December 18th, 2014
MEDICARE QUARTERLY PROVIDER COMPLIANCE NEWSLETTER - Avoid Billing Errors
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 18th, 2014 - Last Review/Update March 1st, 2016
Medicare Quarterly Provider Compliance Newsletters are an educational tool designed to provide education on how to avoid common billing errors and other erroneous activities when dealing with the Medicare Program. It includes guidance to help health care professionals address and avoid the top issues of the particular Quarter.
There are more ...
December 4th, 2014
Collagen Surgical Dressings - Coding Verification Review Requirement
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
In the case of collagen dressings coded A6021, A6022, A6023 and A6024, the predominate component must be collagen.
Effective for claims with dates of service on or after June 1, 2013, the only products which may be billed to Medicare using code A6021, A6022, A6023 and A6024 are those for which ...
December 3rd, 2014
Coding for Laser Therapy
By | Published December 3rd, 2014 - Last Review/Update January 30th, 2017
The Rule of Coding: Service Codes define "what" you do; diagnosis codes define "why" you're doing it. Billing for laser or any other service must be properly defined and supported by both a service code and a diagnosis code.
Coverage for laser, as with any other service, is strictly dependent upon the ...
November 24th, 2014
Billable HCPCS Codes vs. Payable HCPCS Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 24th, 2014 - Last Review/Update August 9th, 2017
The PDAC (Medicares - Pricing, Data Analysis and Coding) receives frequent inquiries regarding a billable HCPCS code and a payable HCPCS code. One may think the two are the same; however, this is not the case.
A billable HCPCS code is one that is submitted on a claim to the DME ...
November 21st, 2014
Risk Adjustment, What is it?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update January 30th, 2017
Risk adjustments are used to compare Actual and Expected Mortality Rates using Risk Adjustments calculated by patient risk score.
BC Risk Adjustment — Risk Adjustment 101
WA Regence Administrative Manual
Risk adjustment is part of the Regence Medicare Program Management for Medicare Advantage plans. Commercial risk adjustment is a requirement of the U.S. Department ...
November 21st, 2014
What is an LMRP and Where Can I Find Them?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
Local Medical Review Policies (LMRPs) were converted to LCDs. This was done as a result of the Benefits Improvement and Protection Act of 2000 (BIPA 2000). The difference between LCDs and previously written LMRPs is that LCDs contain only reasonable and necessary conditions of coverage as allowed under section 1862(a)(1)(A) ...
November 21st, 2014
Establishing a Multi-Disciplinary Practice and Being Legal
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 21st, 2014 - Last Review/Update January 30th, 2017
Q: How do you add another provider type such as a Nurse Practitioner to your practice to provide additional services to patients and legally bill for those services under their license?
A: Multi-disciplinary practices are under scrutiny at the moment by ZPIC, CMS and State Boards. For your reference, just below, there ...
November 17th, 2014
Medicare's Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services
By Wyn Staheli, Director of Research | Published November 17th, 2014 - Last Review/Update January 6th, 2017
Medicare understands that there are individuals who may not meet the diagnostic criteria for substance abuse, but who are still at risk. To help identify these individuals and take steps to keep them from reaching the level of abuse, Medicare has established a program called the Screening, Brief Intervention, and ...
November 5th, 2014
Is Modifier -59 going away?
By | Published November 5th, 2014 - Last Review/Update January 30th, 2017
Anyone who uses modifier 59 needs to be aware that due to problems with the incorrect usage of this modifier (which by the way is also revised for 2015,) CMS has added four new HCPCS modifiers. An announcement by CMS stated that "CMS is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.”
The new codes are:
October 22nd, 2014
Q & A: 97022 and Dry Hydromassage
By | Published October 22nd, 2014 - Last Review/Update January 27th, 2017
Is it appropriate to use 97022, whirlpool, to report dry hydromassage?
The CPT code 97022 is defined simply as “Application of a modality to 1 or more areas; whirlpool”. The CPT book does not expand on the code. However, in 2002, the CPT manual added this phrase to the general guidelines:
Do ...
October 20th, 2014
Clarification of Equipment and Approach in Coding
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 20th, 2014 - Last Review/Update January 30th, 2017
When determining the type of approach taken in a surgical procedure, it is important to review not only the title of the report but also the body of the report to locate the method used.
Somewhere in the body of the report, and always preferably in the title, scope, endoscope, endoscopy ...
October 20th, 2014
Least Expensive Alternative Treatment Clause
By Christine Taxin | Published October 20th, 2014 - Last Review/Update January 27th, 2017
Least Expensive Alternative Treatment Clause
What your patients do not know!
When alternate benefit or LEAT provisions are applied, they are not meant to dictate treatment, question professional judgment or interfere with doctor-patient relationships. The ultimate decision on treatment is up to the dentist and patient. The LEAT provision actually funds a ...
October 17th, 2014
Physical Therapy - Applicable Revenue Codes Rev 09-03-10
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 17th, 2014 - Last Review/Update January 30th, 2017
The appropriate revenue codes for reporting outpatient rehabilitation services are:
0420 - Physical Therapy Services
0430 - Occupational Therapy Services
0440 - Speech-language pathology services
Medicare contractors edit to assure the presence of a HCPCS code when revenue codes 0420, 0430, 0440, or 0470 are reported
Medicare Claims Processing Manual Chapter 5 -Part B Outpatient ...
October 16th, 2014
DMEPOS HCPCS Jurisdiction List
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
HCPCS codes and where to bill them: Local Carrier? DME MAC? Maybe Both?
See the complete list here: NGS -HCPCS Jurisdiction List
...
October 16th, 2014
Incarcerated Beneficiary Update - CMS
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
In 2013, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated on the date of service. CMS subsequently discovered that some of the data used was incomplete. Since some of these recoveries might have been erroneous, CMS initiated refunds. Most of the incarcerated beneficiary erroneous ...
October 16th, 2014
Present on Admission (POA) Indicator
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
To group diagnoses into the proper DRG, CMS needs to capture a Present on Admission (POA) Indicator for all claims involving inpatient admissions to general acute care hospitals. Use the UB-04 Data Specifications Manual and the ICD-9-CM Official Guidelines for Coding and Reporting to facilitate the assignment of the POA indicator ...
October 16th, 2014
Hospital-Acquired Conditions (HAC) in Acute Inpatient Prospective Payment System (IPPS) Hospitals
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
The Deficit Reduction Act of 2005 (DRA) requires a quality adjustment in Medicare Severity Diagnosis Related Group (MS-DRG) payments for certain hospital-acquired conditions. CMS has titled the provision “Hospital-Acquired Conditions and Present on Admission Indicator Reporting” (HAC & POA).
Read more about it here: Medicare learning network fact sheet, ICN 901045 ...
October 16th, 2014
HACs and Codes List 2012
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
For a list of HACs and Codes
Medicare learning network ICN 901045 October 2012
(This list was current with Medicare when published October 2012)
Affected Hospitals
The Hospital-Acquired Conditions payment provision applies only to IPPS hospitals. At this time, the following hospitals are EXEMPT from the HAC payment provision:
Critical Access Hospitals (CAHs)
Long-Term Care Hospitals ...
October 16th, 2014
Final Hospital - Acquired Conditions ( HACs) FY 2014
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017
For a list of the 2014 Final Hospital - Acquired Conditions HACs
Click here: FY 2014 Final Hospital -Acquired Conditions (HACs)
...
October 9th, 2014
Claims Processing and the Remittance Advice
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 9th, 2014 - Last Review/Update January 30th, 2017
After a claim has been submitted and a reimbursement decision has been made, you or your billing agent receive a Remittance Advice (RA). The RA is a notice of payments and adjustments that the MAC produces as a companion to claim payments or an explanation when there is no payment. ...
October 9th, 2014
Physical Therapy Part B Outpatient Rehabilitation and CORF / OPT Services Ch 5 - CMS claims processing manual Rev08-15-2014
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 9th, 2014 - Last Review/Update January 30th, 2017
For detailed information on CMS Claims processing for Part B Outpatient Rehabilitation and Comprehensive Outpatient Rehabilitation Facility (CORF) Services -General
Visit : CMS.gov
...
October 9th, 2014
Physical Therapy - Type of Serivce Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 9th, 2014 - Last Review/Update January 30th, 2017
U = Occupational therapy
W= Physical therapy
Medicare Claims Processing Manual Chapter 5 -Part B Outpatient Rehabilitation and CORF/OPT Services
...
October 9th, 2014
Out Patient Rebab - CORF 75X Bill Types
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 9th, 2014 - Last Review/Update January 30th, 2017
Effective October 1, 2012, the following revenue codes are allowable for reporting CORF services on 75X bill types:
0270
0274
0279
029X
0412
0419
042X
0410
044X
0550
0559
043X
0636
0771
0911
0569
0942
NOTE: Billed revenue codes not listed in the above list will be returned to the provider by Medicare systems. See Chapter 25, Completing and Processing the CMS-1450 Data Set, for revenue code descriptions
...
October 9th, 2014
Filing Corrected Claims
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 9th, 2014 - Last Review/Update January 25th, 2017
A corrected claim is a claim that was originally submitted with incorrect information and is being resubmitted.
When submitting a corrected paper claim, enter the Claim Frequency Type Code 7 or 8 (see below) in BOX 22
7 = Replacement (replacement of prior claim)
8 = Void (void/cancel of prior claim)
Add a note explaining ...
October 9th, 2014
To Participate or Not to Participate, That is The Question.
By Christine Taxin | Published October 9th, 2014 - Last Review/Update January 27th, 2017
Insurance! Can it be profitable or a big loser?
Participating with insurance can initially bring down your revenue as you cut your fees per procedure. It is important to remember that your overhead will not decrease along with the fees. The question is can you make up the revenue by increasing ...
October 3rd, 2014
Effective Billing Dates for new CMS Providers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 3rd, 2014 - Last Review/Update January 30th, 2017
As of May 14, 2012, the billing effective date can be made retroactive as far back as 30 calendar days from the date the application was received in Medicare's office.
Provider offices must submit the CMS 855 form as soon as the provider begins seeing Medicare patients to ensure their services will be ...
September 25th, 2014
Healthcare Fraud Investigations in FY 2013
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
Enforcement Actions in FY 2013: the Department of Justice (DOJ) opened 1,013 new criminal health care fraud investigations involving 1,910 potential defendants. Federal prosecutors had 2,041 health care fraud criminal investigations pending, involving 3,535 potential defendants, and filed criminal charges in 480 cases involving 843 defendants. A total of 718 ...
September 25th, 2014
Virtual Credit Cards -A new trend in trying to keep up with E-Health
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
Beware of the changes sneaking in as “money streams” in the name of EFT standards. Virtual Credit Cards are being used in provider’s offices as payments from payers; clearinghouses are starting to offer this service as well.
Effective January 1, 2014, health plans were required to offer electronic funds transfer (EFT). ...
September 23rd, 2014
CMS - How to Understand Medicare's ID Numbers (HIC or HICN)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 23rd, 2014 - Last Review/Update January 30th, 2017
A HIC number (HICN) is a Medicare beneficiary’s identification number. Also, remember when billing, ALWAYS use the name as it appears on the patient's Medicare card.
Both CMS and the Railroad Retirement Board (RRB) issue Medicare HIC numbers. The format of a HIC number issued by CMS is a Social Security ...
September 18th, 2014
Medicare Electronic Sumbission (EDI) links
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 18th, 2014 - Last Review/Update January 30th, 2017
Helpful links for Electronic submissions (EDI)
See links here:Â NGS EDI Lnks
...
September 18th, 2014
Other Medical Code Sets Find-A-Code Content
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 18th, 2014 - Last Review/Update January 30th, 2017
How many code sets are there?
Find-A-Code Content
Did you know?
Along with the ever so popular code sets we are so familiar with and use every day such as:
ICD-9, ICD-10, DRG’s, CPT, HCPCS, ICD-9 Vol. 3, CDT, ICD-10 PCS, APC and NDC codes,
Find-A-Code has lists of many other code sets (To access ...
September 15th, 2014
Medicare Definition of Timed Codes
By Wyn Staheli, Director of Research | Published September 15th, 2014 - Last Review/Update July 12th, 2016
Many procedure codes are considered "timed codes," that is, the number of units are determined by the amount of time spent performing the service. Medicare Claims Processing Manual, Chapter 5 clarification included here.
September 15th, 2014
Can Chiropractors Bill 99211?
By | Published September 15th, 2014 - Last Review/Update January 30th, 2017
This code would be used rarely in a chiropractic office. 99211 is a low complexity examination for an established patient. It can be used by chiropractors, but in most instances, it is discouraged.
The 99211 code, also known as the nurse's code, is not really made for the physician to use. In fact, the AMA, ...
September 9th, 2014
Do I Need Error and Omissions (E&O) Insurance for My Billing Company?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 9th, 2014 - Last Review/Update January 30th, 2017
Do I Need Error and Omissions (E&O) Insurance for My Billing Company?
Over the years Medical billing has been considered low risk, now it has developed into a huge liability with HIPAA, E&O and Business Associate Agreements to name a few.
HIPAA has rocked the world for small businesses. Looking at the ...
September 9th, 2014
How To Collect, Maintain and Use Insurance Fee Schedules
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published September 9th, 2014 - Last Review/Update January 30th, 2017
Fee SchedulesDo you know what the fee schedules are for each of your top insurance companies? Do your providers know how much they are getting paid for the services they provide and manage their practice to maximize reimbursement?
Learn how to maximize reimbursement by knowing, understanding and using insurance fee schedules ...
August 14th, 2014
Don't Let the New ICD-10 Catch You Off Guard
By David Berky | Published August 14th, 2014 - Last Review/Update January 25th, 2017
The Center for Medicare and Medicaid Services (CMS) has approved the final version for the new ICD-10-CM and ICD-10 PCS. Until coders and billers convert to this new ICD-10-CM coding system on October 1st, 2014 (now 2015), they will continue to use the ICD-9-CM codes and CPT/HCPCS codes. However, CMS is recommending that professionals start this new training and become well versed with these two new ICD-10 code sets.
August 13th, 2014
Consolidated Billing (CB) for SNF (Skilled Nursing Facilities) - Exceptions
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 13th, 2014 - Last Review/Update August 9th, 2017
SNF itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services listed below). CB for SNF resembles the bundling requirement for Inpatient Hospital Services, assigning the facility responsible for the entire package except for certain services that are specifically excluded.
Physicians' services furnished to ...
August 12th, 2014
Un-Timely Filing - ZERO Reimbursement
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 12th, 2014 - Last Review/Update January 25th, 2017
I like to call this a FREE clinic visit; it is a pet peeve of mine to see an office lose money due to timely filing. There is no reason for this type of loss; however it is more and more common. First of all Insurance companies are shortening the time ...
August 7th, 2014
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 7th, 2014 - Last Review/Update January 25th, 2017
Reimbursement for most Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is established by fee schedules. Payment is limited to the lower of the actual charge or the fee schedule amount.  We have given you some basic information to get you started including modifiers and how CMS views DMEPOS, please ...
August 1st, 2014
What Does Accept Assignment Mean?
By Instacode Institute | Published August 1st, 2014 - Last Review/Update March 5th, 2019
What does it mean to accept assignment on the CMS 1500 claim form - also called the HCFA 1500 claim form.? Should I accept assignment or not? What are the guidelines for accepting assignment in box 27 of the 1500 claim?
These commonly asked questions should have a simple answer, but ...
July 31st, 2014
Medicare Requiring Prior Authorization for Power Mobility Devices
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 31st, 2014 - Last Review/Update January 25th, 2017
Due to the fact that Power Mobility Devices have a climbing high rate of fraud and improper payments the Centers for Medicare & Medicaid announced in May it has extended the pre authorization process to 12 more states for power mobility devices. These states include Arizona, Georgia, Indiana, Kentucky, Louisiana, Maryland, ...
July 31st, 2014
Virtual Credit Cards used with E-Health
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 31st, 2014
Beware of the changes sneaking in as “money streams” in the name of EFT standards. I am beginning to see Virtual Credit Cards used in provider’s offices as payments from payers. I am also hearing clearinghouses are offering this service as well. Effective January 1, 2014 health plans were required ...
July 31st, 2014
Fill In Doctor: Locum Tenens
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published July 31st, 2014 - Last Review/Update January 25th, 2017
It is a common practice for a solo doctor to find someone to cover for them while they are away from the office for a temporary or extended period of time, such as medical leave, or vacation. Some offices fail to code properly for the services rendered by the “fill-in” ...
July 31st, 2014
Can Chiropractors Bill 99211?
By | Published July 31st, 2014 - Last Review/Update January 25th, 2017
This code would be used rarely in a chiropractic office. 99211 is a low complexity examination for an established patient. It can be used by chiropractors, but in most instances, it is discouraged. The 99211 code, also known as the nurse's code, is not really made for the physician to use. ...
July 31st, 2014
GP Modifier for Physio Therapy Services
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published July 31st, 2014 - Last Review/Update January 25th, 2017
The -GP modifier needs to be appended to physio-therapy codes when submitting Medicare claims. However, be aware of differing policies for different types of payers. Chiropractors typically use the following Physical Medicine codes from the CPT book: 97010 thru 97799 (except for 97597-97610 for active wound care management). The current ...
July 16th, 2014
The Impact of ICD-10 Coding System on Medical Billing
By David Berky | Published July 16th, 2014 - Last Review/Update January 25th, 2017
Learn how the introduction of ICD-10 will impact the coding and billing of medical diagnosis and procedure.
July 16th, 2014
Windows XP and HIPAA Non-compliance
By Wyn Staheli, Director of Research | Published July 16th, 2014 - Last Review/Update January 25th, 2017
For anyone who is not a computer techie, the announcement by Microsoft about discontinuing support for Windows XP may not mean much. However, from a HIPAA perspective, this is very important information because Section 164.308(a)(5)(ii)(B) of the HIPAA Security Rules includes an 'addressable' requirement of Protection from Malicious Software where ...
July 16th, 2014
G0402: Medicare Preventive Visit
By | Published July 16th, 2014 - Last Review/Update January 25th, 2017
Medicare covers a one-time Initial Preventive Physical Examination (IPPE), also referred to as the “Welcome to Medicare†visit.  IPPE is a unique benefit available only to patients newly enrolled in the Medicare Program and must be received within the first 12 months of the effective date of their Medicare Part ...
July 15th, 2014
How the Internet is Reshaping Medical Coding and Billing
By David Berky | Published July 15th, 2014 - Last Review/Update January 25th, 2017
Since the Internet is affecting (usually for better) every industry, why should it come as a surprise that medical coding and billing is now heavily dependent on the Internet? Actually, a number of important challenges and changes in the healthcare industry, and in technology as a whole, are pushing medical ...
July 8th, 2013
Denials for 97140 (Manual Therapy)? Here's the story.
By | Published July 8th, 2013 - Last Review/Update January 27th, 2017
The ChiroCode Institute has received several inquiries over the last few months regarding a denial for 97140 (Manual therapy—such as myofascial release or trigger point therapy) when billed with 98940-98942 (Chiropractic Manipulative Treatment - CMT) on the same visit. Most payers follow Medicare’s guidelines for the use of this code, ...
April 12th, 2013
Chiropractic Coding & Billing Training - Which Course Is Right For You?
By | Published April 12th, 2013 - Last Review/Update January 27th, 2017
Often times we get calls at ChiroCode from offices looking for training. Sometimes it is due to employee turnover and other times it is from a new office trying to get started. And everyone is looking for affordable help!
There are hundreds of seminars and clinics available for training if you ...
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