CPT 99201 gone in 2021
Virtual Conference
Get ahead of the CPT Evaluation and Management changes taking affect in 2021. Master the changes and learn how they will affect your practice.
- 5 Bootcamp sessions and 18 Symposium sessions
- 14 Presenters including CMS and AMA
- On-demand session videos, purchase as bundles or individually
"Payer: CMS|Medicare" & "HCPCS Coding" Articles
Click on the title to see the article summary and a link to the full article.
January 11th, 2021
Good and Bad News Regarding the 2021 Medicare Physician Fee Schedule
By Wyn Staheli, Director of Research | Published January 11th, 2021
When the proposed Medicare Physician Fee Schedule came out last year, it really got everyone worried. In a time where we are all facing issues related to COVID, this seemed like a really big problem. Professional organizations lobbied and everyone tried to stop the proposed changes, and the 10.2% decrease didn’t happen, but other changes will still be taking place. So how bad is it really and how will it affect your organization?
January 11th, 2021
Instructions for Looking up IOM References in innoviHealth's HCPCS Publication
By Wyn Staheli, Director of Research | Published January 11th, 2021
These instructions help owners of innoviHealth's HCPCS Coding for 2021 book access the references to Medicare's Internet-only Manuals (IOMs) which are copies of official program instructions, policies, and procedures that are based on statutes, regulations, guidelines, models, and directives.
January 5th, 2021
CMS Final Rule Changes E/M Reporting Guidelines
By Wyn Staheli, Director of Research | Published January 5th, 2021
Just when we thought we had figured out Evaluation and Management (E/M) reporting for 2021, CMS released their final rule and now we will need to make some adjustments. While CMS stated that they were adopting the AMA guidelines for E/M office or other outpatient services, they did make a few changes.
December 31st, 2020
CMS Final Rule Changes E/M Reporting Guidelines
By Wyn Staheli, Director of Research | Published December 31st, 2020
Just when we thought we had figured out Evaluation and Management (E/M) reporting for 2021, CMS released their final rule and now we will need to make some adjustments. While CMS stated that they were adopting the AMA guidelines for E/M office or other outpatient services, they did make a few changes.
December 8th, 2020
Final Rule on Communications Technology and 2021 Physicians Fee Schedule
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 8th, 2020
To create a healthcare system that will benefit providers as well as Medicare beneficiaries there have been several new rules issued that begin on or after January 01, 2021. CMS released the final policy and payment provisions on December 01, 2020, which includes the physician fee schedule (PFS) for 2021. ...
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 20th, 2020
CMS Expands Telehealth Again
By Wyn Staheli, Director of Research | Published October 20th, 2020
On October 14, 2020, CMS announced further changes to expand telehealth coverage. Eleven (11) new codes have been added to their list of covered services bringing the current total to 144 services. The new services include some neurostimulator analysis and programming services as well as some cardiac and pulmonary rehabilitation services.
October 7th, 2020
Stay out of Trouble — Understand the Qualified Medicare Beneficiary (QMB) Program
By Wyn Staheli, Director of Research | Published October 7th, 2020
To assist low-income Medicare beneficiaries, CMS created the Qualified Medicare Beneficiary (QMB) program; a Medicaid benefit which pays for Medicare deductibles, coinsurance, or copays for any Medicare-covered items and services for Medicare Part A, Part B, and Medicare Advantage (Part C). Providers/suppliers are prohibited from billing premiums and cost sharing to Medicare beneficiaries who are enrolled in QMB.
September 1st, 2020
Not Following the Rules Costs Chiropractor $5 Million
By Wyn Staheli, Director of Research | Published September 1st, 2020
Every healthcare office needs to know and understand the rules that apply to billing services and supplies. What lessons can we learn from the mistakes of others? What if we have made the same mistake?
August 28th, 2020
New Value-Based Payment Models for Primary Care (Primary Care First and Direct Contracting)
By Jared Staheli | Published August 28th, 2020
This article summarizes the new Medicare value-based payment models: Primary Care First and Direct Contracting.
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...
August 10th, 2020
Coding Injections for Pain Management
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2020
Coding for pain management can get confusing. How many injections, the location, and when to use a modifier are all common questions. This article will cover some of the most common injections used in pain management.
Trigger Point Injections
Trigger point injections are reported by how many muscles are treated using an ...
July 21st, 2020
Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately
By Aimee Wilcox | Published July 21st, 2020
We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...
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 1st, 2020
Additional Practice Reopening Tips
By Wyn Staheli, Director of Research | Published June 1st, 2020
As practices begin reopening across the nation, there are several things that need to be considered. Policies and Procedures Manuals need to be updated, malpractice carriers need to be contacted and everyone needs to consider mental health screenings and support.
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 21st, 2020
Special COVID Laboratory Specimen Coding Information
By Wyn Staheli, Director of Research | Published April 21st, 2020
With all the new laboratory test codes that have been added due to the current public health emergency (PHE), there are a few additional guidelines CMS has released about collecting samples to perform the testing. Please keep in mind that these guidelines are by CMS and may or may not apply to other commercial payer policies.
April 20th, 2020
Emergency Room and Ancillary Services
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 20th, 2020
Billing for an Emergency department is not the same as billing for a hospital or in the provider's office; there are several differences and requirements. For example. the hospital will report a stay with Diagnosis Related Groups (DRG's), which include hospital resources used during the patient's stay, while office visits ...
April 20th, 2020
SOME of Us Non-Essentials May be Able to Get Back on the Road!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 20th, 2020
The day is coming when the freeways will have 5:00 pm stop-and-go traffic again, no doubt. However, when it comes to re-opening our world, CMS has Recommendations!
Changes are finally here; we are starting to see a decline in COVID-19 cases in some states and certain locations. It may be time ...
April 20th, 2020
Now That is Fraud! Genetic Testing "Public alert"
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 20th, 2020
Genetic testing is becoming very popular. In fact, so popular you might see it in places you would not expect such as a community event, fairs or any event happening in your community. Some labs may even offer FREE screening for genetic testing. Watch for FREE screening announcements or advertisements ...
April 15th, 2020
Medicare Released the Amount they Will pay for COVID Testing Eff 4/14/2020
April 13th, 2020
CMS Important Information on COVID-19 Released
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 13th, 2020
CMS has recently released some important information on their last MLN, the highlights are below.
COVID-19: Dear Clinician Letter
CMS posted a letter to clinicians that outlines a summary of actions CMS has taken to ensure clinicians have maximum flexibility to reduce unnecessary barriers to providing patient care during the unprecedented outbreak ...
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.
April 2nd, 2020
More Telehealth Changes Announced by CMS
By Wyn Staheli, Director of Research | Published April 2nd, 2020
On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). See this article for further information as well as references & links to CMS information
March 30th, 2020
Providing Telehealth Services During COVID-19 Crisis
By Wyn Staheli, Director of Research | Published March 30th, 2020
The rules for providing telehealth services during this pandemic have changed and some requirements have been waived. Please keep in mind that “waiving requirements” does not mean that anything goes. Another important consideration is that Medicare and private payers may likely have different rules so you need to make sure that you know individual payer requirements during this time.
March 26th, 2020
2020 Medicare Part D Coverage Gap (AKA donut hole)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 26th, 2020
Not every Medicare drug plan has complete coverage for prescription drugs - most have some sort of coverage gap, known as the “Donut Hole”. The coverage gap is a temporary limit on coverage under the drug plan. This coverage gap will not affect everyone and begins after you have used ...
March 26th, 2020
Medicare Part D Coverage Gap (Donut Hole) Closes in 2020
By Jared Staheli | Published March 26th, 2020
Overview of the Part D coverage gap, how it got closed, what the picture looks like for 2020, and long-term outlook.
March 26th, 2020
LATEST COVID-19 INFORMATION FOR BILLING NON-FACE-TO-FACE SERVICES
By Namas | Published March 26th, 2020
Healthcare providers and the population at large are concerned about safe access to care considering the COVID-19 pandemic. As a result, we have received many inquiries this week about how to bill for “telehealth” services.
Let’s first address that true telehealth services have some pretty stringent requirements from CMS, including that ...
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 ...
March 20th, 2020
Implementing Telehealth Visits
By Namas | Published March 20th, 2020 - Last Review/Update March 23rd, 2020
The following is a step-by-step guide on how to convert office-based encounters to telehealth encounters during the current COVID-19 pandemic. These rules may change post-pandemic, as many changes relaxing existing rules were made on a temporary basis by CMS and commercial payers to facilitate patient access and minimize risk of infection.
Step ...
March 17th, 2020
Additional Coronavirus Testing Code Announced
By Wyn Staheli, Director of Research | Published March 17th, 2020
On March 13, 2020, a new CPT code was announced by the American Medical Association (AMA) who maintains the CPT code set. This early release of a CPT code is rare and is effective immediately.
February 20th, 2020
New HCPCS Code for Coronavirus Testing Announced
By Wyn Staheli, Director of Research | Published February 20th, 2020 - Last Review/Update February 26th, 2020
Currently, healthcare providers testing patients for Coronavirus must use an unspecified code. To provide better tracking, on February 13, 2020, CMS announced the creation of a new HCPCS code.
February 19th, 2020
Medicare Begins Covering Acupuncture Services
By Wyn Staheli, Director of Research | Published February 19th, 2020
Medicare is changing their policy regarding coverage of acupuncture, but in order to provide these services, you must follow their rules.
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 ...
January 7th, 2020
Denials due to MUE Usage - This May be Why!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 7th, 2020
CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...
January 6th, 2020
CMS Report on QPP Shows Increasing Involvement
By Wyn Staheli, Director of Research | Published January 6th, 2020
MIPS 2018 participation increased according to the final report issued by CMS on January 6, 2020.
December 30th, 2019
Medicare Changes Bilateral Reporting Rules for Certain Supplies
By Wyn Staheli, Director of Research | Published December 30th, 2019 - Last Review/Update January 6th, 2020
DME suppliers must bill bilateral supplies with modifiers RT and LT on separate claim lines or they are being rejected.
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 19th, 2019
CMS- Patient Driven Payment Model Effective October 01, 2019
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 19th, 2019
According to CMS, In July 2018, CMS finalized a new case-mix classification model, the Patient-Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay.
Using the new Patient-Driven ...
December 9th, 2019
CMS says Codes are on the Move!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 9th, 2019
Have you noticed your LCDs are missing something? CMS is moving codes out of LCDs and into Billing and Coding Articles. MACs began moving ICD-10-CM, CPT/HCPCS, Bill Type, and Revenue codes in January 2019, and will continue through January 2020. Therefore, if there is an LCD with its codes removed, you will find ...
December 3rd, 2019
Q/A: Can I Order a TENS unit for a Medicare Patient?
By Wyn Staheli, Director of Research | Published December 3rd, 2019 - Last Review/Update December 4th, 2019
Question
Can a chiropractor order a TENS unit for a Medicare patient? We cannot order X-rays for a Medicare patient so I assume we cannot order a TENS unit either.
Answer
It’s not that you can’t order the TENS unit, it’s just that when it comes to doctors of chiropractic, Medicare only covers ...
November 11th, 2019
And Then There Were Fees...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 11th, 2019
Find-A-Code offers fees and pricing for just about everything, this article will address two of some of the most common payment systems with CMS. (OPPS) -Outpatient Medicare Outpatient Prospective Payment System. (MPFS)- Medicare Physician Fee Schedule The Fees section on each code page is determined on the type of services...
October 11th, 2019
Why is HIPAA So Important?
By Namas | Published October 11th, 2019 - Last Review/Update October 15th, 2019
Why is HIPAA So Important?
Some may think that what they do to protect patient information may be a bit extreme. Others in specialty medical fields and research understand its importance a little more. Most of that importance lies in the information being protected. Every patient has a unique set of ...
September 30th, 2019
Vaccine Administration - When The Right Vaccine Code is Not Enough
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 30th, 2019
Understanding how to apply immunization administration codes properly will support correct reimbursement for vaccinations. Reporting the right vaccine code alone is not enough to guarantee proper billing. The majority of the time, providers can charge for the vaccine/product as well as the administration of the vaccine; always consult your payer ...
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
Healthcare Common Procedure Coding System (HCPCS)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 13th, 2019
There are three main code sets and Healthcare Common Procedure Coding System (HCPCS), is the third most common code set used. They are often called Level II codes and are used to report non-physician products supplies and procedures not found in CPT, such as ambulance services, DME, drugs, orthotics, supplies, ...
August 13th, 2019
Will Medicare Change Their Rules Regarding Coverage of Services Provided by a Chiropractor?
By Wyn Staheli, Director of Research | Published August 13th, 2019
Two separate pieces of legislation introduced in the House of Representatives (H.R. 2883 and H.R. 3654) have the potential to change some of Medicare’s policies regarding doctors of chiropractic. Find out what these two bills are all about and how they could affect Medicare policies.
August 13th, 2019
Q/A: I Billed 2 Units of L3020 and Claim was Denied. Why?
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published August 13th, 2019
Question:
We billed 2 units of L3020 but were denied for not using the right modifiers. What should we do?
Answer:
Rather than submitting two units of the L3020 to indicate that the patient one orthotic for each foot, you would need to use modifiers identifying left foot and right foot. Appropriate coding ...
August 6th, 2019
CMS Proposes to Reverse E/M Stance to Align with AMA Revisions
By Wyn Staheli, Director of Research | Published August 6th, 2019
On July 29, 2019, CMS released their proposed rule for the Medicare Physician Fee Schedule for 2020. Last year’s final rule “finalized the assignment of a single payment rate for levels 2 through 4 office/outpatient E/M visits beginning in CY 2021.” It also changed some of the documentation requirements (e.g., ...
August 2nd, 2019
The Slippery Slope For CDI Specialists
By Namas | Published August 2nd, 2019 - Last Review/Update August 8th, 2019
Who knew that when Jack & Jill when up the hill to fetch a pail of water, they would have to ensure that in order to keep the level of water the same on the way back down, they would need to both support the pail.
Many of you in this industry are ...
July 26th, 2019
Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage
By Namas | Published July 26th, 2019 - Last Review/Update August 8th, 2019
Anthem has been very busy sending out notices stating that, beginning October 1, 2019, all timely filing deadlines for claims will be 90 days. We've seen this letter, or something very similar, sent to doctors and other healthcare providers from California to Kentucky.
In their notice, Anthem states:
"Effective for all commercial ...
July 15th, 2019
Denial Management is Key to Profitability
July 9th, 2019
When Can You Bill Orthosis Components Separately?
By Wyn Staheli, Director of Research | Published July 9th, 2019
Othoses often have extra components. When can you bill those components separately? For example, can you bill for a suspension sleeve (L2397) with a knee orthosis (e.g., L1810)?
July 8th, 2019
Will the New Low Level Laser Therapy Code Solve Your Billing Issues?
By Wyn Staheli, Director of Research | Published July 8th, 2019
Low level laser therapy (LLLT), also known as cold laser therapy, is a form of phototherapy which uses a device that produces laser beam wavelengths, typically between 600 and 1000 nm and watts from 5–500 milliwatts (mW). It is often used to treat the following:
Inflammatory conditions (e.g., Rheumatoid Arthritis, Carpal ...
July 5th, 2019
Helping Others Understand How to Apply Incident to Guidelines
By Namas | Published July 5th, 2019 - Last Review/Update July 16th, 2019
Over the past few months, I have worked with different organizations that have been misinterpreting the "incident to" guidelines and, in return, have been billing for services rendered by staff that are not qualified to perform the services per AMA and CPT. What I found within the variances is that ...
July 1st, 2019
Q/A: Do I Really Need to Have an Interpreter?
By Wyn Staheli, Director of Research | Published July 1st, 2019
Question:
I heard that I need to have an interpreter if someone who only speaks Spanish comes into my office. Is this really true?
Answer:
Yes! There are both state and federal laws that need to be considered. The applicable federal laws are:
Title VI of the Civil Rights Act of 1964,
Americans with Disabilities ...
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 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
Medicare Approves Reimbursement for Virtual Communication (G2012)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Medicare has taken a stand to recognize communication technology-based services by approving two newly defined physicians' services that will significantly help providers who deal with phone calls and patient triage. One of these services includes:
Virtual check-in (G2012), which allows the provider to be reimbursed for communicating with the patient via ...
June 13th, 2019
Medicare Now Reimburses for Remote Monitoring Services (G2010)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Medicare's 2019 Final Rule approved HCPCS code G2010 for reimbursement, which allows providers to be paid for remote evaluation of images or recorded video submitted to the provider (also known as "store and forward") to establish whether or not a visit is required. This allows providers to get paid for ...
June 13th, 2019
Now is Your Chance to Speak Up! Tell CMS What You Think!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 13th, 2019
CMS is asking for your input, we all have ideas on how we would change healthcare documentation requirements and get rid of the burdensome requirements and regulations if it were up to us, so go ahead, speak up! Patients over Paperwork Initiative is being looked at to help significantly cut ...
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.
May 8th, 2019
Facts on Procedure Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 8th, 2019
There are two levels of codes used for services and procedures:
Level I Codes are used for Services and Procedures provided by physicians.
5 digit numerical code, example, 99213 - Office or other outpatient visits
Level II Codes are used to bill Medical equipment supplies and transport services.
4 digit Alpha/Numerical code example, ...
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 26th, 2019
Medicare Revises Their Appeals Process
By Wyn Staheli, Director of Content | Published April 26th, 2019
There are policy revisions in the Medicare Claims Processing Manual (MCPM), Chapter 29 taking place June 13, 2019. This will give you a heads up on those changes.
April 24th, 2019
Biofeedback - Is it Medically Necessary?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 24th, 2019
Biofeedback is used for many reasons, and most commonly used for pain management. Each payer should be consulted with to verify coverage when treating with Biofeedback to verify if the treatment is considered experimental or investigational.
The majority of payers will list Biofeedback on an exclusions list. Others such as BC ...
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 8th, 2019
Q/A: What do I do When a Medicare Patient Refuses to Sign an ABN?
By Wyn Staheli, Director of Research | Published April 8th, 2019
Question: What do I do when a Medicare patient refuses to sign an ABN?
Answer: That depends on whether the patient is still demanding to have/receive the service/supply. If they aren’t demanding the service, then there is no need to force the issue. Just make sure that you still have an ...
April 1st, 2019
Spinal Cord Stimulator Used for Chronic Pain
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 1st, 2019
Chronic pain is a condition that can be diagnosed on its own or diagnosed as a part of another condition. When coding chronic pain, there is no time frame defining when pain becomes chronic pain; the provider’s documentation should be used to guide the use of these codes.
ICD-10-CM Diagnosis Codes ...
April 1st, 2019
Corrections and Updates
By Wyn Staheli, Director of Research | Published April 1st, 2019 - Last Review/Update April 2nd, 2019
One constant in our industry is change. Policies change, contracts change, and there are updates. Also, people aren’t perfect and mistakes can be made. So this article will cover a variety of topics.
Published Articles
We appreciate feedback from our valued customers. We have received feedback regarding two of our articles which ...
April 1st, 2019
Q/A: Can I Tell a Medicare Patient Which Option to Check on the ABN?
By Wyn Staheli, Director of Research | Published April 1st, 2019 - Last Review/Update April 2nd, 2019
Question
My patient seemed confused about which of the options they should check. Can I just tell them which one they should check?
Answer
No! That could be construed as coercion. The official instructions state “Under no circumstances can the notifier decide for the beneficiary which of the 3 checkboxes to select.”
Now, this ...
March 25th, 2019
Clearing Up Some Medicare Participation Misunderstandings
By Wyn Staheli, Director of Research | Published March 25th, 2019 - Last Review/Update April 2nd, 2019
Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for ...
March 11th, 2019
Spotlight: Services Excluded from Global Surgery Payment
By Brittney Murdock, QCC, CMCS, CPC | Published March 11th, 2019
The following services are excluded from global surgery payment according to Noridian Medicare. These services may be paid for separately. The initial consultation or evaluation of the problem by the surgeon to determine the need for surgery. Please note that this policy only applies to major surgical procedures. The initial...
March 7th, 2019
Date of Service Reporting for Radiology Services
By Wyn Staheli, Director of Research | Published March 7th, 2019
Providers need to ensure that they are reporting radiology dates of service the way the payer has requested. Unlike other many other professional services which only have one date of service (DOS), radiology services can span multiple dates. Medicare requirements may differ from professional organization recommendations.
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
Billing Guidelines for Repositioning
By Wyn Staheli, Director of Research | Published March 4th, 2019 - Last Review/Update March 6th, 2019
Code 95992 has some very limited payer payment guidelines which need to be understood for proper reimbursement. Many payer policies consider this service bundled with Evaluation and Management Services, therefore, it would not be separately payable if there was an E/M service performed on the same date. Some providers have reported having trouble ...
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).
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 ...
February 11th, 2019
HHS Proposes Significant Changes to Patient Access Rules
By Wyn Staheli, Director of Research | Published February 11th, 2019
In a significant announcement on February 11, 2019, HHS proposed new rules aimed at improving interoperability of electronic health information. This announcement was made in support of the MyHealthEData initiative which was announced by the Trump administration on March 6, 2018. The goal of that initiative was to break down ...
February 7th, 2019
Charging Missed Appointment Fees for Medicare Patients
By Wyn Staheli, Director of Research | Published February 7th, 2019 - Last Review/Update February 8th, 2019
Some providers mistakenly think that they cannot bill a missed appointment fee for Medicare beneficiaries. You can, but Medicare has specific rules that must be followed. These rules are outlined in the Medicare Claims Policy Manual, Chapter 1, Section 30.3.13. You must have an official “Missed Appointment Policy” which is ...
February 1st, 2019
Physical Therapy Caps Q/A
By Wyn Staheli, Director of Research | Published February 1st, 2019 - Last Review/Update February 4th, 2019
Question: How do I code it so that PT services in a chiropractic office don’t count against their PT visit max? Is there a way to code claims so that they are considered chiropractic only? But still get compensated enough? We have been running into some issues as of late ...
February 1st, 2019
Attestations Teaching Physicians vs Split Shared Visits
By BC Advantage | Published February 1st, 2019 - Last Review/Update February 7th, 2019
Physicians often use the term "attestation" to refer to any kind of statement they insert into a progress note for an encounter involving work by a resident, non-physician practitioner (NPP), or scribe. However, for compliance and documentation purposes, "attestation" has a specific meaning and there are distinct requirements for what ...
January 28th, 2019
Empowering Medicare Beneficiaries
By Find-A-Code | Published January 28th, 2019 - Last Review/Update January 29th, 2019
BLOG: CMS announced a NEWS release today making it easier to help Medicare Beneficiaries access cost and quality information. CMS announced, "Today, the Centers for Medicare & Medicaid Services (CMS) launched a new app that gives consumers a modernized Medicare experience with direct access on a mobile device to some of ...
January 24th, 2019
Q/A: Which Code Should I Use for a Lab Interpretation Fee?
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published January 24th, 2019 - Last Review/Update February 4th, 2019
Question
Which code should I use for a lab interpretation fee? Specifically, I have ordered a female hormone saliva test, and would like to charge a fee for time spent on the interpretation and consult.
Answer
This type of service generally does not involve a third party, so it may be acceptable to ...
January 23rd, 2019
Everything You need to Know about Drugs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 23rd, 2019
We have it all! Search our WK Drug Database for drugs and pharmaceuticals. When it comes to support and guidance the WK Drug Database offers a paramount search and is conveniently presented in one place.
Pricing
GPIs
NDCs
Billing Codes
Indications/Diseases
Packaging Information
Active and Inactive
and more...
Additionally, learn more about drugs and pharmaceuticals that can be used to detect, treat, or monitor ...
January 22nd, 2019
Home Oxygen Therapy
January 14th, 2019
What is Virtual Communication (G0071)?
By NAMAS | Published January 14th, 2019 - Last Review/Update January 16th, 2019
Beginning January 1st, 2019 all of our RHC and FQHC organizations have a new CPT code to
consider implementing for their Medicare populous (check per Advantage Plan Administration for coverage). In its current form, this code is not reportable by organizations not meeting the RHC/FQHC designation.
The code isG0071 and is termed ...
January 14th, 2019
Q/A: Is G8730 Still Required? Are G Codes Required at all?
By Wyn Staheli, Director of Research | Published January 14th, 2019 - Last Review/Update January 21st, 2019
G8730, when is it required. Many G codes are still active and are required for non-quality reporting.
January 3rd, 2019
CMS Finalizes Major Changes to ACO Program
By Wyn Staheli, Director of Research | Published January 3rd, 2019
Back in August of 2018, as part of the Medicare Shared Savings Program (Shared Savings Program), CMS proposed some sweeping changes for Accountable Care Organizations (ACOs). There has been some controversy over these changes which require ACOs to move to two-sided models. In this Final Rule which was scheduled to be published in the Federal Register ...
January 3rd, 2019
2019 Coding Changes for Chiropractic
By Wyn Staheli, Director of Research | Published January 3rd, 2019
The new year is upon us and so it’s time to double check and make sure we are ready. Those with Premium Membership can use the ChiroCode Online Library and search all the official code sets: ICD-10-CM, CPT, and HCPCS. It also includes the updated NCCI edits and RVUs for ...
December 18th, 2018
Medicare Advantage Providers are not Required to be Enrolled in Medicare
By Wyn Staheli, Director of Research | Published December 18th, 2018
There was a ruling that was requiring providers to be enrolled in Medicare in order to provide services for Part C (Medicare Advantage (MA)) and/or Part D. However, on April 2, 2018, CMS released the 2019 Final Rules for MA and Part D which changed this previous ruling. According to ...
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 29th, 2018
Billing Exercise Equipment
By Wyn Staheli, Director of Research | Published November 29th, 2018
While equipment for home strengthening is arguably good for the patient and the prognosis of their condition(s), payers have very strict guidelines as to what is considered medically necessary when it comes to Durable Medical Equipment (DME). While I have seen some workers compensation policies which do pay for DME ...
November 26th, 2018
Allergy Immunotherapy Coding Guidelines (CMS) Effective: 01/01/2006
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 26th, 2018
Immunotherapy (Allergy Shots) is a medical treatment to used to treat and prevent reactions or desensitize the immune system to specific allergens that trigger allergy symptoms. Payers have specific coverage guidance and rules for reporting injections, the specific type of antigen(s) provided and how they should be reported.
Below are the coding guidelines from ...
November 7th, 2018
Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?
By Wyn Staheli, Director of Research | Published November 7th, 2018
The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...
November 7th, 2018
Medi-Cal Coverage Criteria for Hospital Beds and Accessories
By Raquel Shumway | Published November 7th, 2018
Medi-Cal coverage of child and adult hospital beds and accessaries. What is covered and what documentation is required.
November 1st, 2018
CMS: Medicare Diabetes Prevention Program Expanded Model
By Find-A-Code | Published November 1st, 2018
CMS announces the Medicare Diabetes prevention program is now a new covered service. Per a recent MLN news release. Medicare Beneficiaries will be notified in 2019 in a Medicare handout. Diabetes affects more than 25 percent of Americans aged 65 or older, and its prevalence is projected to increase approximately...
October 17th, 2018
Wolters Kluwer Drug Pricing
By Find-A-Code | Published October 17th, 2018
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
October 16th, 2018
Pelvic Floor Dysfunction Treatment Coverage
By Wyn Staheli, Director of Research | Published October 16th, 2018
Pelvic floor dysfunction is often the underlying cause of conditions such as pelvic pain; urinary or bowel dysfunction; and/or sexual symptoms. Treatment generally begins with an evaluation and testing (e.g, EMG) followed by a variety of services (e.g., biofeedback, manipulation, pelvic floor electrical stimulation), depending on the findings.
Coverage by payers ...
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 ...
August 30th, 2018
Keys to Successful Claims Filing
By Noridian Medicare | Published August 30th, 2018
There are many factors that can contribute to your success in filing claims and getting reimbursed. The information below is from the CMS website.
Completing Item 12, Patient's or Authorized Person's Signature, on the CMS-1500 form for a non-assigned claim
A signature on file (SOF) indicates the supplier has obtained the beneficiary's one-time authorization on ...
August 16th, 2018
Importance of Depression Screenings
By Wyn Staheli, Director of Research | Published August 16th, 2018
Why would a chiropractor be concerned about depression screenings when you aren’t trained to be a mental health provider? The answer lies in patient outcomes. Many quality care organizations recommend depression screenings for patients with a chronic condition. According to The National Institute of Mental Health, “People with other chronic ...
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 15th, 2018
BREAKING NEWS: CMS Proposes to Change E&M Coding
By | Published August 15th, 2018
On July 16th 2018, anyone subscribed to the CMS Quality Payment Program received an e-mail containing a letter to doctors from Seem Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS). There are some widespread changes proposed in this letter of which you need to be aware.
Where ...
July 27th, 2018
Risky Business The CMS HCC Risk Model
By Terry Ketchersid, MD, MBA | Published July 27th, 2018 - Last Review/Update September 24th, 2018
Today's catchy title may invoke memories of that risqué movie from the 80's starring a young Tom Cruise famously dancing in his "tighty whities." But today's post is not about that type of risk. Instead we are going to spend some time with a risk adjustment model that's quietly become...
July 25th, 2018
CMS Proposes Changes to Evaluation & Management Requirements
By Wyn Staheli, Director of Research | Published July 25th, 2018
It is no secret that providers have long argued that E/M coding is burdensome and does not truly reflect the services provided. This fact is acknowledged by CMS with the following statement "Prior attempts to revise the E/M guidelines were unsuccessful or resulted in additional complexity due to lack of ...
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 18th, 2018
Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?
By | Published July 18th, 2018
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed.
For ...
July 18th, 2018
Patients Over Paperwork?! We have Great News!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 18th, 2018
Spend more time with patients and less time documenting? Great Concept!
Document meaningful information? Sound good?
CMS is proposing just that! CMS released a new proposal July 12, 2018, focused on streamlining clinician billing and expanding access to high-quality care. The goal is to improve and restore the doctor-patient relationship, modernize Medicare ...
July 17th, 2018
Attention Providers - Please Make Time to Read this Letter
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 17th, 2018
In an effort to show CMS is committed to changing the rules to accommodate their providers CMS released a letter to Doctors of Medicare Beneficiaries. The letter offers encouragement and a promise to reduce the burden of unnecessary rules and requirements. The letter states “President Trump has made it clear that ...
July 16th, 2018
CMS Proposed New E/M Codes for Podiatry
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 16th, 2018 - Last Review/Update July 17th, 2018
According to CMS changes are coming for E/M codes. A recent proposal from CMS stated: "The E/M visit code set is outdated and needs to be revised and revalued." Since podiatry tends to furnish a lower level of E/M visits, CMS is proposing new G-codes to report E/M office/outpatient visits. The proposed ...
July 12th, 2018
Dual Medicare-Medicaid Billing Problems
By Wyn Staheli, Director of Research | Published July 12th, 2018
It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added):
A state plan must provide ...
July 9th, 2018
Documentation: Face to Face for Home Health Certification
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2018
As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care.
Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. The ...
July 9th, 2018
ESRD Claims Error: Transitional Drug Adjustment Add-On Payment Adjustment
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2018
Medicare sent out a news release to inform of incorrect reimbursement and correction.
"End Stage Renal Disease (ESRD) claims are incorrectly reimbursed if they:
Are eligible for Transitional Drug Adjustment Add-On Payment Adjustment and
Contain non-covered charges
After we fix the system on January 1, 2019, your Medicare Administrative Contractor will mass adjust claims ...
June 25th, 2018
How Does the Physician Compare Website Affect You?
By Wyn Staheli, Director of Research | Published June 25th, 2018
The physician compare website may not be working quite the way you think it is. Not all providers will have rankings showing up for them. Physician compare lists basic information, but quality measure information was not added until this year (2018) and not all quality measures are included in the ...
June 22nd, 2018
Q/A: Do I Have a Patient with Part C sign an ABN if we are Out-of-Network?
By Wyn Staheli, Director of Research | Published June 22nd, 2018 - Last Review/Update January 28th, 2019
Do we need an ABN if the patient has Part C and we are out-of-network? Read More.
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 11th, 2018
Inappropriate Use of Units Costs Practice Over $800,000
By Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | Published June 11th, 2018
A recent OIG enforcement action emphasizes the need to understand the proper use of units. A healthcare provider in Connecticut improperly submitted multiple units for drug screening urine tests. The proper billing of units has proven to be problematic for more than just lab tests. Is your billing of drugs & biologicals, injections and timed codes appropriate?
June 4th, 2018
How Many Modalities Are Too Many?
By Dr Evan Gwilliam, Clinical Director for PayDC chiropractic EHR software | Published June 4th, 2018 - Last Review/Update January 30th, 2019
Q: I have a payor who is denying modalities, claiming that they are “excessive”. At a single encounter I billed for:
98940- Chiropractic manipulative treatment (CMT); spinal, 1-2 regions
97110- Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility
G0283- Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care
97010- Application of a modality to 1 or more areas; hot or cold packs
Is this excessive? How do I know how much is too much?
June 4th, 2018
Why Is Medicare Denying My Claims for Mammography and Breast Biopsies?
By BC Advantage | Published June 4th, 2018
When Medicare updated their systems with the updates to mammography and breast biopsy policies some ICD-10-CM codes were inadvertently left out. The omitted new codes are N63.11-N63.14, N63.21-N63.24, N63.31, N63.32, N63.41, and N63.42, which will replace the truncated ICD-10 diagnosis N63. The Centers for Medicare & Medicaid Services (CMS) will...
May 30th, 2018
EM Code Changes in CPT 2018
By Amy C. Pritchett, BSHA, CCS, CPC, CPMA, CPC-I, CEDO, CANPC, CASCC, CEDC, CRC, ICDCT-CM/PCS | Published May 30th, 2018 - Last Review/Update June 4th, 2018
It is that time of year again! The time to throw out the old and bring in the new. With the release of the CPT 2018 updates, we will see major changes in coding throughout the E/M section.
May 30th, 2018
Creating a Culture of Compliance in 2018
By Sean M. Weiss & Frank Cohen | Published May 30th, 2018 - Last Review/Update June 4th, 2018
This year (2018), healthcare organizations (Hospitals, Health Systems, and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency. Focusing on "compliance"-only approaches leaves healthcare organizations exposed to areas of liability oftentimes far more than what they could ever imagine or even...
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 9th, 2018
Preventive Medicine: General Procedures
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update July 30th, 2018
Preventive Medicine Topics Page
General Procedures
Procedure Codes 36415: Collection of venous blood by venipuncture 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) 90472: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List ...
May 9th, 2018
Preventive Medicine: Alcohol Misuse Screening & Counseling
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update July 30th, 2018
Preventive Medicine Topics Page
// Alcohol Misuse Screening and Counseling
Procedure Codes G0442: Annual alcohol misuse screening, 15 minutes G0443: Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes 99408: Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to ...
May 9th, 2018
Preventive Medicine: Annual Wellness Visit
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Annual Wellness Visit
Procedure Codes G0438: Annual wellness visit; includes a personalized prevention plan of service (pps), initial visit G0439: Annual wellness visit, includes a personalized prevention plan of service (pps), subsequent visit 99385: Initial comprehensive preventive medicine evaluation and management of an individual including ...
May 9th, 2018
Preventive Medicine: Bone Mass Measurements
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Bone Mass Measurements
Procedure Codes G0130: Single energy x-ray absorptiometry (sexa) bone density study, one or more sites; appendicular skeleton (peripheral) (eg, radius, wrist, heel) 76977: Ultrasound bone density measurement and interpretation, peripheral site(s), any method 77078: Computed tomography, bone mineral density study, 1 or more ...
May 9th, 2018
Preventive Medicine: Breastfeeding Supplies
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Breastfeeding Supplies
Procedure Codes A4286: Locking ring for breast pump, replacement E0602: Breast pump, manual, any type E0603: Breast pump, electric (ac and/or dc), any type E0604: Breast pump, hospital grade, electric (ac and / or dc), any type S9443: Lactation classes, non-physician provider, per session
ICD-10-CM ...
May 9th, 2018
Preventive Medicine: Colorectal Cancer Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Colorectal Cancer Screening
Procedure Codes G0104: Colorectal cancer screening; flexible sigmoidoscopy G0105: Colorectal cancer screening; colonoscopy on individual at high risk G0106: Colorectal cancer screening; screening sigmoidoscopy, barium enema G0121: Colorectal cancer screening; colonoscopy on individual not meeting criteria for high risk G0122: Colorectal cancer screening; barium ...
May 9th, 2018
Preventive Medicine: Contraceptive Methods
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Contraceptive Methods
Procedure Codes A4261: Cervical cap for contraceptive use A4266: Diaphragm for contraceptive use A4264: Permanent implantable contraceptive intratubal occlusion device(s) and delivery system J7300: Intrauterine copper contraceptive J7301: Levonorgestrel-releasing intrauterine contraceptive system (skyla), 13.5 mg J7303: Contraceptive supply, hormone containing vaginal ring, each J7304: ...
May 9th, 2018
Preventive Medicine: Counseling to Prevent Tobacco Use
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Counseling to Prevent Tobacco Use
Procedure Codes 99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
ICD-10-CM 99406-99407: No specific diagnoses
Frequency 99406-99407: 2 attempts a year, ...
May 9th, 2018
Preventive Medicine: Depression Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Depression Screening
Procedure Codes G0444: Annual depression screening, 15 minutes 96127: Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
ICD-10-CM G0444, 96127: No specific diagnoses
Frequency G0444:Once annually 96127: No specific frequency guidelines
Additional Information 96127
Only covered for ages ...
May 9th, 2018
Preventive Medicine: Diabetes Self-Management Training
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Diabetes Self-Management Training
Procedure Codes G0108: DSMT, individual, per 30 minutes G0109: GDSMT, group (2 or more), per 30 minutes
ICD-10-CM G0108-G0109: Contact payer for more specific guidelines
Frequency G0108-G0109
Initial year: Up to 10 hours of initial training within a continuous 12-month period
Subsequent years: Up to 2 ...
May 9th, 2018
Preventive Medicine: Glaucoma Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Glaucoma Screening
Procedure Codes G0117: Glaucoma screening for high risk patients furnished by an optometrist or ophthalmologist G0118: Glaucoma screening for high risk patient furnished under the direct supervision of an optometrist or ophthalmologist
ICD-10-CM G0117-G0118: Z13.5
Frequency G0117-G0118: Once a year
Additional information G0117-G0118
Coverage as is indicated with ...
May 9th, 2018
Preventive Medicine: Hepatitis B Virus (HBV) Vaccine and Administration
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Hepatitis B Virus (HBV) Vaccine and Administration
Procedure Codes G0010: Administration of hepatitis b vaccine 90739: Hepatitis B vaccine (HepB), adult dosage, 2 dose schedule, for intramuscular use 90740: Hepatitis B vaccine (HepB), dialysis or immunosuppressed patient dosage, 3 dose schedule, for intramuscular use 90743: Hepatitis ...
May 9th, 2018
Preventive Medicine: Hepatitis C Virus (HCV) Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Hepatitis C Virus (HCV) Screening
Procedure Codes G0472: Hepatitis c antibody screening, for individual at high risk and other covered indication(s) 87522: Infectious agent detection by nucleic acid (DNA or RNA); hepatitis C, quantification, includes reverse transcription when performed 86804: Hepatitis C antibody; confirmatory test (eg, ...
May 9th, 2018
Preventive Medicine: Human Immunodeficiency Virus (HIV) Screening
By Brandon Herman, QMC, QMCC, QMBHC, QMPM, QMPoC | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Human Immunodeficiency Virus (HIV) Screening
Procedure Codes G0432: Infectious agent antibody detection by enzyme immunoassay (eia) technique, hiv-1 and/or hiv-2, screening G0433: Infectious agent antibody detection by enzyme-linked immunosorbent assay (elisa) technique, hiv-1 and/or hiv-2, screening G0435: Infectious agent antibody detection by rapid antibody test, hiv-1 ...
May 9th, 2018
Preventive Medicine: Influenza Virus Vaccine and Administration
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Influenza Virus Vaccine and Administration
Procedure Codes Q2034: Influenza virus vaccine, split virus, for intramuscular use (agriflu) Q2035: Influenza virus vaccine, split virus, when administered to individuals 3 years of age and older, for intramuscular use (afluria) Q2036: Influenza virus vaccine, split virus, when administered to individuals ...
May 9th, 2018
Preventive Medicine: Initial Preventive Physical Examination
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Initial Preventive Physical Examination (Medicare Only)
Procedure Codes G0402: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 12 months of medicare enrollment G0403: Electrocardiogram, routine ecg with 12 leads; performed as a screening for the initial preventive physical examination with interpretation ...
May 9th, 2018
Preventive Medicine: Medical Nutrition Therapy and Cardiovascular Disease (CVD)/Obesity Prevention
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Medical Nutrition Therapy and Cardiovascular Disease (CVD)/Obesity Prevention
Procedure Codes G0270: Medical nutrition therapy; reassessment and subsequent intervention(s) following second referral in same year for change in diagnosis, medical condition or treatment regimen (including additional hours needed for renal disease), individual, face to face with the patient, ...
May 9th, 2018
Preventive Medicine: Lung Cancer Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Lung Cancer Screening
Procedure Codes G0296: Counseling visit to discuss need for lung cancer screening (ldct) using low dose ct scan (service is for eligibility determination and shared decision making) G0297: Low dose ct scan (ldct) for lung cancer screening S8092: Electron beam computed tomography (also ...
May 9th, 2018
Preventive Medicine: Newborn Screenings/Tests
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Newborn Screenings/Tests
Procedure Codes 82775: Galactose-1-phosphate uridyl transferase; quantitative 83498: Hydroxyprogesterone, 17-d 82017: Acylcarnitines; quantitative, each specimen 82136: Amino acids, 2 to 5 amino acids, quantitative, each specimen 82261: Biotinidase, each specimen 83020: Hemoglobin fractionation and quantitation; electrophoresis (eg, A2, S, C, and/or F) 83021: Hemoglobin ...
May 9th, 2018
Preventive Medicine: Pneumococcal Vaccine and Administration
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Pneumococcal Vaccine and Administration
Procedure Codes G0009: Administration of pneumococcal vaccine 90670: Pneumococcal conjugate vaccine, 13 valent (PCV13), for intramuscular use 90732: Pneumococcal polysaccharide vaccine, 23-valent (PPSV23), adult or immunosuppressed patient dosage, when administered to individuals 2 years or older, for subcutaneous or intramuscular use
ICD-10-CM G0009, ...
May 9th, 2018
Preventive Medicine: Prostate Cancer Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Prostate Cancer Screening
Procedure Codes G0102: Prostate cancer screening; digital rectal examination G0103: Prostate cancer screening; prostate specific antigen test (PSA)
ICD-10-CM G0102-G0103: Z12.5
Frequency G0102-G0103: Once annually
Additional Information G0102-G0103
Only for males aged 50 and older
G0102
Copayment and deductible may apply, consult your payer
Find-A-Code™ - Preventive Services - ...
May 9th, 2018
Preventive Medicine: Screening for STIs & HIBC to Prevent STIs
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Screening for STIs and High Intensity Behavioral Counseling (HIBC) to Prevent STIs
Procedure Codes 86592: Syphilis test, non-treponemal antibody; qualitative (eg, VDRL, RPR, ART) 86593: Syphilis test, non-treponemal antibody; quantitative 86631: Antibody; Chlamydia 86632: Antibody; Chlamydia, IgM 86780: Antibody; Treponema pallidum 87110: Culture, chlamydia, any source ...
May 9th, 2018
Preventive Medicine: Screening Pap Tests
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Screening Pap Tests
Procedure Codes G0123: Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, screening by cytotechnologist under physician supervision G0124: Screening cytopathology, cervical or vaginal (any reporting system), collected in preservative fluid, automated thin layer preparation, requiring interpretation ...
May 9th, 2018
Preventive Medicine: Screening Gynecological Examination
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Screening Gynecological Examination
Procedure Codes G0101: Cervical or vaginal cancer screening; pelvic and clinical breast examination S0610: Annual gynecological examination; clinical breast examination without pelvic evaluation S0612: Annual gynecological examination, established patient S0613: Annual gynecological examination, new patient
ICD-10-CM G0101:Low risk patients - Z01.411, Z01.419, Z12.4, Z12.72, ...
May 1st, 2018
Webinar: Basic E&M Avoiding Common Errors
By Find-A-Code | Published May 1st, 2018
Join us for AAPC CEU approved Education and Outreach with Noridian BASIC E AND M AVOIDING COMMON ERRORS Start Date: 5/15/18 Duration: 11:00 AM – 12:00 PM - Pacific Daylight Time Type: Web-based Workshop Register Now: https://attendee.gotowebinar.com/register/7977003427311130113 Abstract: This presentation is designed to provide basic information on the billing and...
April 26th, 2018
Documenting DMEs
By Find-A-Code | Published April 26th, 2018
As per MLN MM8304,
This article is based on Change Request (CR) 8304, which instructs DME MACs to implement requirements, which are effective July 1, 2013, for detailed written orders for face-to-face encounters conducted by the physician, PA, NP or CNS for certain DME items as defined in 42 CFR 410.38(g).
Due to concerns ...
April 20th, 2018
The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?
By Robert Liles, JD, MBA, MS | Published April 20th, 2018 - Last Review/Update April 25th, 2018
As the Medicare program has grown, the Centers for Medicare and Medicaid Services (CMS) has employed a variety of different claims audit mechanisms to better ensure that the Medicare Trust Fund is protected from waste, fraud and abuse....
April 19th, 2018
Coverage Criteria for Nonwearable Automatic Defibrillators
By Find-A-Code | Published April 19th, 2018
According to Noridian and CGS Administrators LCD L33690, a nonwearable automatic defibrillator (E0617) is covered for beneficiaries in two circumstances. They meet either (1) both criteria A and B or (2) criteria C, described below:
The beneficiary has one of the following conditions (1-8):A documented episode of cardiac arrest due to ventricular fibrillation, not due to a ...
April 16th, 2018
Indications for Serotypes A and B Botulinum Toxins
By Find-A-Code | Published April 16th, 2018
According to Novitas LCD L27476, the following indications apply:
1. Blepharospasm and strabismus2. Spastic dystonia or focal dystonias to relieve pain, to assist posturing and walking, to increase range of motion, to assist in the outcome of physical therapy, and/or to reduce spasm thus allowing adequate perineal hygiene.3. Spasmodic dysphonia4. Achalasia and cardiospasm when ...
April 12th, 2018
Billing Nutrition Counseling in a Chiropractic Setting
By Wyn Staheli, Director of Research | Published April 12th, 2018
Billing nutrition counseling services may not be as straight-forward as you might think. Some providers mistakenly choose Medical Nutrition Therapy (MNT) codes (97802-97804, G0270, G0271) because it states nutrition therapy in the title. However, according to CPT guidelines, when MNT assessment and/or intervention is performed by a physician or qualified healthcare professional ...
April 12th, 2018
Billing Nutrition Counseling
By Wyn Staheli, Director of Research | Published April 12th, 2018
Billing nutrition counseling services may not be as straight-forward as you might think. Some providers mistakenly choose Medical Nutrition Therapy (MNT) codes (97802-97804, G0270, G0271) because it states nutrition therapy in the title. However, according to CPT guidelines, when MNT assessment and/or intervention is performed by a physician or qualified healthcare professional who may report evaluation and management ...
April 9th, 2018
Coverage Criteria for Peripheral Venous Examinations
By Find-A-Code | Published April 9th, 2018
According to National Government Services LCD L33627, indications for venous examinations are separated into three major categories: deep vein thrombosis (DVT), chronic venous insufficiency, and vein mapping. Studies are medically necessary only if the patient is a candidate for anticoagulation, thrombolysis or invasive therapeutic procedure(s).
Since the signs and symptoms of ...
April 9th, 2018
CMS Compliance Guidelines Focused Trainings
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 9th, 2018
Since the publication of the Compliance Program Guidelines in 2012, the Medicare Part C & D Oversight and Enforcement Group, Division of Compliance Enforcement, has presented a series of focused trainings for the industry on the application of the seven elements of an effective compliance program. These trainings are designed ...
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 21st, 2018
Medicare Beneficiary Identifier (MBI) Beginning April 1, 2018 (This is Not a Joke)
By Brittney Murdock, QCC, CMCS, CPC | Published March 21st, 2018
The law requires the Centers for Medicare & Medicaid Services (CMS) to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new unique Medicare number will replace the current Health Insurance Claim Number (HICN) on the new Medicare cards. The new cards will be mailed in...
March 21st, 2018
Q/A: Billing for GI Anesthesia
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 21st, 2018 - Last Review/Update March 27th, 2018
Medicare’s policy requires the use of a different code when a screening colonoscopy becomes a diagnostic procedure requiring you to bill with CPT code 00811 when treating a Medicare Beneficiary.
March 9th, 2018
Documentation for Ordering Oxygen Supplies and Equipment
By Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 26th, 2018
The Medicare Learning Network provides guidance on required documentation for Ordering Oxygen Supplies and Equipment.
March 9th, 2018
Documentation for Negative Pressure Wound Therapy
By Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for negative pressure wound therapy.
March 9th, 2018
Documentation for Surgical Dressings
By Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for surgical dressings.
March 9th, 2018
Documentation for Urological Supplies
By Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for urological supplies.
March 9th, 2018
Documentation for Enteral Nutrition
By Medicare Learning Network | Published March 9th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for enteral nutrition. ...
March 8th, 2018
Documentation for Home Blood Glucose Monitors (BGM)
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 14th, 2018
The Medicare Learning Network provides guidance on how to Prevent Denials for Home Blood Glucose Monitors (BGM)...
March 8th, 2018
Documentation for Therapeutic CGMs and Related Supplies
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 14th, 2018
The Medicare Learning Network, provides coverage guidance on therapeutic CGMs and Related Supplies
March 8th, 2018
Documentation for Manual Wheelchairs
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning network provides guidance on how to prevent denials for Manual Wheelchair Bases....
March 8th, 2018
Documentation for Lower Limb Prosthesis
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning Network provides guidance on denials for lower leg prostheses and how to prevent them:
For the 2017 report period, most of the improper payments for lower leg prostheses were due to insufficient documentation.
For Medicare to cover a lower limb prosthesis claim, the medical record must support the beneficiary’s ...
March 8th, 2018
Documentation for Bacterial Culture Lab Tests
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning Network provides guidance on how to prevent denials of Bacterial Culture Laboratory Tests
March 8th, 2018
Documentation for Bacterial Culture Lab Orders
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning Network provides guidance on delivering orders for bacterial culture laboratory tests...
March 8th, 2018
Documentation for Power Tilt/Recline Seating Systems for Wheelchairs
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning Network provides coverage guidance for Power Tilt and/or Recline Seating Systems...
March 8th, 2018
Documentation for Ostomy Supplies
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 15th, 2018
The Medicare Learning Network provides guidance on essential documentation elements required to prevent denials for ostomy supplies....
March 8th, 2018
Documentation for Home Health Services (Part A non DRG)
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018
The Medical Learning Network provides coverage guidance, which should be documented, for home health services.
March 8th, 2018
Documentation and Orders for Respiratory Assistive Device
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for a respiratory assistive device and ordering guidelines.
March 8th, 2018
Documentation and Orders for Laboratory Tests
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for ordering laboratory tests.
March 8th, 2018
Documentation for Skilled Nursing Facilities
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for Skilled Nursing Facilities (SNF).
March 8th, 2018
Documentation for Inpatient Rehabilitation Facilities
By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018
The Medicare Learning Network provides guidance on required documentation for Inpatient Rehabilitation Facilities (IRF).
March 1st, 2018
New Bipartisian Budget Act of 2018 Provisions
By Wyn Staheli, Director of Research | Published March 1st, 2018
On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. There were some changes which will affect Medicare payments. The following is a brief summary, for a more comprehensive summary see the References.
Therapy Caps: Some therapy caps (e.g., occupational, physical therapy, speech-language pathology) were discontinued. However, modifier KX will ...
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 26th, 2018
Q/A: With a Maintenance Patient of Medicare age that has a Medicare Replacement Plan (Part C), do They Need to Fill out an ABN?
By Wyn Staheli, Director of Research | Published February 26th, 2018 - Last Review/Update February 4th, 2019
Q/A: With a maintenance patient of medicare age that has a medicare replacement plan (Part C), do they need to fill out an ABN?
February 26th, 2018
Medicare Changes Requirements for Implantable Cardioverter Defibrillators (ICDs)
By Wyn Staheli, Director of Research | Published February 26th, 2018
Whenever there is a high-cost item, CMS has historically evaluated usage to determine appropriateness of billing and this is another example. A Decision Memo was released on February 15, 2018 which included the following changes:
Changes to who qualifies for a device and the required waiting periods
Patient registry no longer required
Cardiac magnetic resonance ...
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 21st, 2018
No HCPCS Code Available? Now What?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 21st, 2018
HCPCS level II codes classify products into categories for the purpose of claims processing. HCPCS level II codes are alphanumeric with a descriptive terminology that identifies the item or service used primarily for billing purposes.
There are several types of HCPCS level II codes such as:
Permanent National Codes
Dental Codes
Miscellaneous Codes
Temporary National ...
February 13th, 2018
Payment Rates Increase for Behavioral Health Office Services
By Wyn Staheli, Director of Research | Published February 13th, 2018
Behavioral health providers may see some improvement in payment rates for office-based behavioral health services. This is due to the fact that the overhead expense evaluation portion of the RVU was increased. The following information is from the Federal Register (see References):
We agree with these stakeholders that the site of service ...
February 6th, 2018
Medicare Using Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting January 2018
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 6th, 2018
On June 17, 2016, CMS announced the release of its final rule implementing section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA). This final rule requires reporting entities to report private payor rates paid to laboratories for lab tests, which will be used to calculate Medicare payment ...
February 1st, 2018
Patients Undergoing a Bone Marrow Transplant (BMT)
By Find-A-Code | Published February 1st, 2018
Accoring to Wisconsin Physicians Service Insurance Corporation L34699, when using J2820 for patients undergoing a bone marrow transplant (BMT), 2 diagnosis codes are required:1) Z76.82 Awaiting organ transplant status2) Pick a code from one of these categories:
C81- Hodgkin Lymphoma
C82- Follicular Lymphoma
Non-follicular Lymphoma
C83.1- Mantle cell lymphoma
C83.3- Diffuse large B-cell lymphoma
C83.7- Burkitt lymphoma
C83.8- Other (Intravascular large B-cell lymphoma, Primary effusion B-cell lymphoma, or Lymphoid granulomatosis)
Mature T/NK-cell lymphomas
C84.4- Peripheral T-cell ...
February 1st, 2018
How to Code Screening and Diagnostic Colonoscopy
By Natalie Tornese, CPC | Published February 1st, 2018
The following information is from BC Advantage.
Colonoscopy is a common procedure performed byGastroenterologists. CPT defines a colonoscopy examination as "the examination of the entire colon, from the rectum to the cecum or colon-small intestine anastomosis, and may include examination of the terminal ileum or small intestine proximal to an anastomosis" ...
February 1st, 2018
CMS Changes Definitions for Therapeutic Shoe Inserts
By Wyn Staheli, Director of Research | Published February 1st, 2018
CMS recently revised their definitions for custom fabricated and therapeutic inserts in order to meet current technology standards. Healthcare providers need to be sure to review the revisions in order to appropriately bill Medicare for inserts. For example, for custom fabricated, molded-to-patient, they have added the following:
iii. For inserts used with ...
February 1st, 2018
MAC Operations Continue During Shutdown
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 1st, 2018
CMS announced today, during the time that the partial government shutdown is in effect, Medicare Administrative Contractors will continue to perform all functions related to Medicare fee-for-service claims processing and payment.
...
February 1st, 2018
Strapping and Kinesio Taping Coding Differences
By Wyn Staheli, Director of Research | Published February 1st, 2018
There are differences between the purposes of strapping and taping and using the correct codes depends on the application - literally.
Strapping: This application is for the purpose of immobilizing an area. It is clinically indicated for the treatment of fractures, dislocations, sprains/strains, tendonitis, post-op reconstruction, contractures, or other deformities involving soft tissue.
Coding: ...
February 1st, 2018
Multiple Diagnostic Imaging Payment Reduction
By Wyn Staheli, Director of Research | Published February 1st, 2018
CMS and some other payers have adopted policies of reducing payments when certain multiple diagnostic imaging procedures (see Applicable Codes below) are performed in a single session by the same healthcare provider and/or group. They have done the same when there are multiple units for a procedure code. The rationale ...
January 31st, 2018
Influenza, Are You Billing Correctly?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 31st, 2018
With this year's Flu season being the most widespread on record, providers are seeing more patients and giving more immunizations for influenza than normal. Here are a few things to keep in mind during this flu season.
Know the rules with your payers to ensure proper reimbursement and correct billing. For example, did you ...
January 25th, 2018
Psychiatric Partial Hospitalization Programs
By Wyn Staheli, Director of Research | Published January 25th, 2018
Psychiatric Partial Hospitalization Programs (PHPs) are a more comprehensive level of care than Intensive Outpatient Programs (IOPs - click here to read more about IOPs). When the patient requires a minimum of 20 hours per week and hospitalization is not clinically indicated, a PHP can be the most effective type of ...
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
Medicare's Integrated Behavioral Healthcare Services and Collaborative Care Program
By Wyn Staheli, Director of Research | Published January 18th, 2018
Over the last several years, primary care has begun to integrate behavioral health services to better address shortfalls in patient quality of care. Some of the first codes were the Health and Behavior Assessment/Intervention (96152-96155) codes, which were added in 2002. Since then, many different models have been experimented with and have ...
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 15th, 2018
Billing with a GP Modifier
By Wyn Staheli, Director of Research | Published January 15th, 2018 - Last Review/Update January 30th, 2019
Q: When patients have a true Medicare secondary insurance we've always billed other Medicare non-covered codes such as G0283 for electric stimulation with modifier GY because we are aware Medicare will not pay for that service but the secondary insurance does. We just were notified by our MAC that GY is not a valid modifier and I have to enter a GP or other therapy modifier. What is the new proper modifier to enter?
January 11th, 2018
Intensive Outpatient Treatment (IOP)
By Wyn Staheli, Director of Research | Published January 11th, 2018
Intensive Outpatient Programs (IOPs) are considered to be an intermediate level of care which is commonly considered after the patient has been discharged from inpatient care. For some patients and/or conditions they can also provide an effective level of care when hospitalization is not clinically indicated or preferred. The following ...
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 10th, 2018
New Payment Model launched by CMS- Bundled Payments for Care Improvement Advanced (BPCI Advanced).
January 10th, 2018
New MIPS Reporting Option for 2017 Data
By Wyn Staheli, Director of Research | Published January 10th, 2018
On January 2, 2018, CMS announced a new data submission system for eligible clinicians to report quality measures for the Quality Payment Program. Data may be submitted through the new platform on the qpp.cms.gov website. The announcement stated:
Data can be submitted and updated any time from January 2, 2018 to March ...
January 10th, 2018
MIPS - To Participate or Not Participate - That is the Question
By Wyn Staheli, Director of Research | Published January 10th, 2018
Medicare’s Merit-based Incentive Payment System (MIPS) Final Rule increased the threshold for participation. With this increase, a significant number of providers fall into the exempt category and they are now breathing a sigh of relief. However, there’s one hidden tidbit which you may have missed - the potential damage to ...
January 9th, 2018
Diagnosis billing with J0888
By Find-A-Code | Published January 9th, 2018
The following information is from LCD L36276.
The diagnosis codes listed below require the use of the EC modifier (ESA administered to treat anemia not due to anti-cancer radiotherapy or anti-cancer chemotherapy) when submitting claims for J0888. In addition, these diagnosis codes are marked with an * indicating they require a dual diagnosis. The ...
January 9th, 2018
Coverage and/or Medical Necessity for the Use of Hyaluronan or Derivitive
By Find-A-Code | Published January 9th, 2018
According to Palmetto GBA, Medicare will cover the cost of the injection and the injected hyaluronate polymer for patients who meet the following clinical criteria:
Knee pain associated with radiographic evidence of osteophytes in the knee joint, sclerosis in bone adjacent to the knee, or joint space narrowing.
Morning stiffness of less than 30 minutes in duration or crepitus on motion of the ...
January 9th, 2018
Billing Electrotherapy with AcuKnee
By Christine Woolstenhulme | Published January 9th, 2018
This code is commonly used to bill for AcuKnee products. Per AcuKnee, “NMES and electrotherapy may be covered by most insurance providers, provided the following criteria are met;”
Documentation of chronic pain or muscle atrophy 3 months or longer
Must document improvement
Must have physician document medical necessity/Prescription
Appropriate authorization from your insurance provider
Suggested codes when billing
64550 initial electrotherapy education and placement
E0720 Electrotherapy unit itself
E0731 Garment ...
January 9th, 2018
Outpatient Rehabilitation Modifiers
By Jared Staheli | Published January 9th, 2018
Modifiers are used for outpatient rehabilitation services to identify the type of service performed. This is necessary for payers to determine service coverage for beneficiaries.
For services delivered under an outpatient plan of care use modifier:
GN for speech-language pathology
GO for occupational therapy
GP for physical therapy
In addition to using the correct modifier, ...
January 5th, 2018
Medicare Reimburses for Discarded/Wasted Drugs
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 5th, 2018
Your organization may be leaking revenue without realizing the leak can be stopped. If your organization purchases single-use packets or single dose vials for individual patient use and ends up discarding some of the drug, Medicare has now authorized payment for the discarded or wasted portion. Stop leaking revenue today by reading this article and implementing the guidance provided here.
January 4th, 2018
Beware of Limitations When Using Electrical Stimulation - Ultrasound
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 4th, 2018
Ultrasound is often used to reduce inflammation, and improve the flexibility of connective tissue. This is done by applying sound waves to produce heat and/or vibration. Be aware of the many limitations when reporting this code. Be sure to consult your local carrier LCDs and carefully determine the correct code and the requirements for ...
January 4th, 2018
CMS Launches Data Submission System for Clinicians in the Quality Payment Program
By Find-A-Code | Published January 4th, 2018
Today, the Centers for Medicare & Medicaid Services (CMS) announced that doctors and other eligible clinicians participating in the Quality Payment Program can begin submitting their 2017 performance data using a new system on the Quality Payment Program website (qpp.cms.gov). The data submission system is an improvement from the former...
January 4th, 2018
Filing a CMS-1500 Claim form to Medicare PUB-100 40.1.1.1
By Find-A-Code | Published January 4th, 2018
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 (i.e., ...
January 4th, 2018
Proper Usage of Electrical Stimulation
By Find-A-Code | Published January 4th, 2018
According to CGS Administrators, most non-wound care electrical stimulation treatment provided in therapy should be billed as G0283 as it is often provided in a supervised manner (after skilled application by the qualified professional/auxiliary personnel) without constant, direct contact required throughout the treatment.
97032 is a constant attendance electrical stimulation modality ...
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
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
2017-2018 Influenza (Flu) Resources for Health Care Professionals
By Find-A-Code | Published January 4th, 2018
Per CMS: Medicare provides coverage of the flu vaccine without any out-of-pocket costs to the Medicare patient. No deductible or copayment/coinsurance applies. Annual Part B deductible and coinsurance amounts do not apply.
Payment allowance limits for personal flu and pneumococcal vaccines are 95 percent of the Average Wholesale Price (AWP), except where the vaccine is furnished ...
January 3rd, 2018
Abuse, Neglect, or Maltreatment
By Wyn Staheli | Published January 3rd, 2018
According to the official ICD-10-CM Guidelines, in situations of maltreatment (e.g., adult and child abuse, neglect, etc.), the sequence of coding is important. Regardless of whether it is suspected or confirmed, it is important to document the type of abuse. Use the following sequence:
An appropriate code from category T74- (confirmed) or T76- (suspected)
Any accompanying mental ...
January 2nd, 2018
Quality Payment Program in 2018
By Wyn Staheli, Director of Research | Published January 2nd, 2018 - Last Review/Update January 30th, 2019
I checked the government website to see if I am an eligible clinician and it says that I am not. I just don't want to get blindsided with a letter saying I will be penalized. Is there anything you would suggest or recommend that I do now to protect myself from future penalties. Thank you
December 28th, 2017
Sleep Testing
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 28th, 2017
Once a patient has been evaluated for symptoms associated with sleep apnea, testing is ordered to identify severity and determine treatment.
There are several types of sleep tests, but coverage is based on meeting the criteria for Type I (inpatient facility based) or Type II-IV and Other (home-based sleep tests). All ...
December 28th, 2017
Alcohol Misuse Screening and Counseling
By Wyn Staheli | Published December 28th, 2017
Codes G0442 (screening) and G0443 (15 min counseling) are typically a covered preventive service for most payers. As a preventive service, copayment/coinsurance and deductibles are typically waived. These are NOT considered treatment services or sessions for alcoholism or other substance abuse. If the screening results indicate that the patient is dependent and is open to the ...
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 13th, 2017
Specialty Exceptions — 2018 PE RVU Changes
By Raquel | Published December 13th, 2017
Some specialties are not included in the new PPIS PE/HR RVU changes
December 13th, 2017
Appropriate Use Criteria for Advanced Diagnostic Imaging Services - 2018 Final Rule
By Jared Staheli | Published December 13th, 2017
What is the AUC program? From the CMS website:
Section 218(b) of the Protecting Access to Medicare Act of 2014 amended Title XVIII of the Social Security Act to add section 1834(q) directing CMS to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging ...
December 12th, 2017
Medicare Diabetes Prevention Program (MDPP) Expanded Model Information
By Jared Staheli | Published December 12th, 2017
Diabetes treatment places an ever-increasing strain on the resources of the U.S. healthcare system. CMS estimated that in 2016 alone, Medicare incurred an additional $42 billion in costs due to the number of beneficiaries with diabetes. The best way to keep these costs down in the future is by preventing ...
December 11th, 2017
Quality Payment Program Resources
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 11th, 2017
CMS posted new Merit-based Incentive Payment System (MIPS) resources on Quality Payment Program Resource Library webpage:
CMS Web Interface: Excel template for uploading sample beneficiary data with corresponding user guide and instructional video
Extreme and Uncontrollable Circumstances Fact Sheet: Overview of the policy established in the interim final rule with comment period to support clinicians affected by the California wildfires and ...
December 4th, 2017
Revised ABN and Non-Participating Providers
By Wyn Staheli, Director of Research | Published December 4th, 2017
Non-participating providers have the option to strikeout part of the ABN form.
November 28th, 2017
Medicare Expands Value Based Plans
By Wyn Staheli, Director of Research | Published November 28th, 2017
In 2015, the CMS Innovation Center announced plans for new value-based Medicare Advantage plans in an effort to reduce healthcare costs while improving quality of care. This five year pilot program began in 2017 with seven states and is expanding to ten states for 2018. Results must have been positive because they ...
November 27th, 2017
Erythropoietin Stimulating Agents (ESA)
By Wyn Staheli, Director of Research | Published November 27th, 2017
Coverage
ESA is typically covered for the following condition(s):
Treatment of anemia associated with chronic renal failure (whether or not that patient is on dialysis)
Treatment of significant anemia in patients with non-myeloid malignancies where anemia is due to the effect of concomitantly administered chemotherapy
Treatment of anemia due to AZT and/or other Nucleoside Reverse Transcriptase Inhibitors (NRTI) used in treatment of HIV/AIDS
Treatment of selected ...
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 27th, 2017
Speech-Language Pathology Services Policy from UniCare
By Find-A-Code | Published October 27th, 2017
Medically Necessary:
Rehabilitative speech-language pathology (SLP) services are considered medically necessary when ALL of the following criteria are met:
The services are used in the treatment of communication impairment or swallowing disorders resulting from illness*, injury, surgery, or congenital abnormality; and
Based on a plan of care, the therapy sessions achieve a specific ...
October 18th, 2017
Avoid Deactivation of your Medicare Billing Privileges
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 18th, 2017
According to the Affordable Care Act all Medicare providers are required to re-validate their enrollment information every three or five years. To determine if you are due for re-validation the list below will display a re-validation due date. If you have a due date of “TBD”, this means there has not ...
October 18th, 2017
Physicians Reciprocal Billing Arrangements
October 13th, 2017
Can Chiropractors Opt-out of Medicare?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published October 13th, 2017 - Last Review/Update February 5th, 2019
Chiropractors cannot opt-opt of Medicare. Does that only refer to chiropractors that see Medicare patients? Do all Florida chiropractors have to complete Medicare enrollment/credentialing? Bottom line- do ALL chiropractors, no matter where or who, have to complete Medicare enrollment since they cannot Opt-out?
October 5th, 2017
Q/A: Do we Need to Charge for Non-covered Services Performed Under a Maintenance Visit if we Use the S8990 Code When Billing Medicare?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published October 5th, 2017 - Last Review/Update February 5th, 2019
Do we need to charge for non-covered services performed under a maintenance visit if we use the S8990 code when billing Medicare?
September 30th, 2017
Annual Wellness Visit & Health Risk Assessment
By Find-A-Code | Published September 30th, 2017 - Last Review/Update October 1st, 2017
Coding tips regarding Annual Wellness Visit and Health Risk Assessments
September 20th, 2017
Bladder/Urothelial Tumor Markers (Jurisdiction F)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 20th, 2017
CMS recently released a new LCD for Jurisdiction F, Bladder/Urothelial Tumor Markers (L36680).
Documentation Requirements
The medical record must clearly identify the number and frequency of bladder marker testing. Medical record documentation must be legible, must be maintained in the patient’s medical record (hard copy or electronic copy), and must meet the ...
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
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: Colorectal Cancer 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 Colorectal Cancer Screening.....
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 29th, 2017
Quality Measures for Chiropractic - 2017
By Wyn Staheli, Director of Research | Published August 29th, 2017
Performance Measurement Codes for Chiropractic:
Although there are hundreds of Performance Measurement (PM) services and events, only two may be reported for chiropractors for the 2017 reporting year.
Pain Assessment and Follow-Up
131
ENCOUNTER: 90791, 90792, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 96116, 96118, 96150, 96151, 97161, 97162, 97163, 97164, 97165, 97166, 97167, ...
August 25th, 2017
Changes to the Medicare Appeals Process
By Sean Weiss, CHC, CMCO, CEMC, CPMA, CMPE, CPC-P, CPC | Published August 25th, 2017 - Last Review/Update January 31st, 2018
On June 29th, The Centers for Medicare and Medicaid (CMS) issued the Medicare Program: "Changes to the Medicare Claims and Entitlement, Medicare Advantage and Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures final rule."
August 24th, 2017
Q/A: MIPS and G Codes
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published August 24th, 2017 - Last Review/Update February 5th, 2019
We have one doctor in our practice who qualifies under the MIPS guidelines so he is continuing to use the PQRS and G-codes. We are having the rest of our doctors do the same, just in case, and because it is good practice, but is that completely unnecessary and can it possibly do us more harm than good?
August 18th, 2017
The Incredible Disappearing Consultation
By J. Paul Spencer, CPC, COC | Published August 18th, 2017 - Last Review/Update January 25th, 2018
In January of 2010, CMS ceased payment of CPT codes for consultations (99241 through 99245 for outpatient, and 99251 through 99255 for inpatient).
August 4th, 2017
List of Common Unclassified Injectable drugs (this list in not all-inclusive)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 4th, 2017
This is a list of some of the most common Injectable unclassified drugs used with J3490
Antilirium – 1 mg/ml
Ascorbic Acid – 500 mg/ml
Ascorbic Acid – 250 mg/ml
Bacitracin, Intramuscular – 50,000 unit vials
Bacitracin, Intramuscular – 10,000 unit vials
Brevital Sodium – 500 mg/5 ml
Caffeine and Sodium Benzoate – 250 mg/ml
Capastat Sulfate – 1 ...
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
Requirements for Physicians Orders for DME/HCPCS
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 1st, 2017
Effective July 1, 2013, certain DME/HCPCS codes require a valid detailed written order prior to delivery. There are very specific rules and requirements requiring medical necessity and orders/prescriptions. It is also required to keep a copy in the patients chart. If billing CMS and commercial payers payers, the DME prescribed may be denied ...
August 1st, 2017
Annual Wellness Visit (AWV)
By Wyn Staheli, Director of Research | Published August 1st, 2017
Annual Wellness Visits (AWVs) are a preventive medicine service. It is a comprehensive evaluation and management service which is covered by payers as part of the Affordable Care Act (ACA)'s covered services and there are typically no deductibles or co-pays.
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 26th, 2017
HCPCS Codes - ASP Reporting is done in Units not NDC
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 26th, 2017
HCPCS CODES FOR WHICH ASP REPORTING IS DONE IN UNITS OF MEASURE OTHER THAN AN NDC Updated November 14, 2016
A9587 GALLIUM GA-68, DOTATATE, DIAGNOSTIC, 0.1 MILLICURIE 0.1 millicurie
A9588FLUCICLOVINE F-18, DIAGNOSTIC, 1 MILLICURIE 1 millicurie
A9606 RADIUM RA-223 DICHLORIDE, THERAPEUTIC, PER MICROCURIE 1 microcurie
C9132 PROTHROMBIN COMPLEX CONCENTRATE (HUMAN), KCENTRA, PER I.U. OF FACTOR IX ACTIVITY 1 IU
C9140 INJECTION, FACTOR VIII (ANTIHEMOPHILIC FACTOR, RECOMBINANT) (AFSTYLA), 1 I.U. 1 IU
J0256 INJECTION, ALPHA 1 PROTEINASE INHIBITOR ...
July 7th, 2017
Telemedicine: The Next Frontier in Care Delivery
By Valora Gurganious, MBA, CHBA | Published July 7th, 2017 - Last Review/Update January 25th, 2018
Technology is ubiquitous in modern society, and just when we thought that computers could not replace the "human touch" of a healthcare provider, technology is making specialized care accessible to patients anywhere there is an internet connection.
June 30th, 2017
Treating Diabetic Patients in Your Office?
By Shannon DeConda | Published June 30th, 2017
CMS will be rolling out an Expanded Diabetes Prevention Plan January 1, 2018 as well as new Durable Medical Equipment (DME) supply codes for Continuous Glucose Monitors (CGM) July 1, 2017. These services will offer your practice the opportunity to better assist your diabetic patient's needs.
Remember that prior to providing ...
June 29th, 2017
New payments for Psychiatric Collaborative Care Services (COCM) from Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 29th, 2017
Medicare has agreed to make separate payments to physicians and non-physicians for Behavioral Health Integration (BHI) services beginning Jan. 1st, 2017.
Any condition new or pre-existing behavioral health or substance use disorders are eligible. Beneficiaries may have comorbid, chronic, or other medical conditions they are being treated for as well.
Using the ...
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 27th, 2017
Modifier JW With Drug Codes
By Find-A-Code | Published June 27th, 2017
Modifier JW
In the past, some Medicare Administrative Contractors have required providers to report wasted drugs with modifier JW (Drug amount discarded/not administered to any patient). Use of the modifier was at the contractor’s discretion, and some contractors told providers not to report it. But effective January 1, 2017, all providers ...
June 20th, 2017
Changes with DME
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 20th, 2017
Due to the cost and refills that is required with portable oxygen systems separate payment classes were added in 2007 for oxygen generating portable equipment. Each year, Payment Classes for Oxygen Generating Portable Equipment, Stationary Oxygen Contents, and Portable Oxygen Contents, are adjusted to make additional payment classes for oxygen ...
May 12th, 2017
When Using Code 99050 (After Hours)
By | Published May 12th, 2017 - Last Review/Update February 8th, 2019
Question: When using code 99050 (after hours), do I just add a amount, example $25.00, to our normal total charges for that patients visit?
May 12th, 2017
NGS E/M Code Changes for 2017
By ChiroCode | Published May 12th, 2017 - Last Review/Update January 31st, 2019
The Medicare contractor, NGS, made changes to its E/M coding guidelines for level 3 exams. Even if you don't bill NGS, this change could be a sign of things to come for other payers. Watch here.
April 26th, 2017
Modifiers: Reporting Wound Dressings
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 26th, 2017 - Last Review/Update July 28th, 2017
When reporting dressings for wounds, it is important to indicate if the dressing is the primary or secondary dressing as well the number of wounds the dressing will be used for.
Primary Dressing: May be therapeutic or protective coverings applied to wounds either on the skin or caused by an opening ...
April 20th, 2017
Billing Dermal Filler Injections
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 20th, 2017 - Last Review/Update July 28th, 2017
When billing dermal filler injections, separate payment may be made under the OPPS and ASC payment systems for HCPCS G0429- Dermal filler injection(s) for the treatment of facial lipodystrophy syndrome (lds) (e.g., as a result of highly active antiretroviral therapy).
Use in addition: Q2026- Injection, radiesse, 0.1 ml, and Q2028 - Injection, sculptra, 0.5 mg
With a diagnosis of B20 - ...
March 29th, 2017
Newly Revised "Common Procedure Codes" section in the 2016 ChiroCode DeskBook
By Evan M. Gwilliam, DC MBA BS CPC CCPC NCICS CPC-I CCCPC MCS-P CPMA | Published March 29th, 2017
The force used to create a degree of tension of soft tissues and/or to allow for separation between joint surfaces. The degree of traction is controlled through the amount of force (pounds) allowed, duration (time), and angle of pull (degrees) using mechanical means. Terms often used in describing pelvic/cervical traction ...
March 28th, 2017
Respiratory Assist Devices (RAD) E0470 and E0471 - Billing Reminders
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 28th, 2017 - Last Review/Update July 28th, 2017
Add the KX modifier to all claims for RADs and accessories for the first through third months if all thecoverage criteria have been met.
Add the KX modifier to all claims for the fourth month and thereafter if all the coverage criteria have been met and if the physician signed and dated a ...
March 27th, 2017
Devices Used for Treatment with TMJ
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 27th, 2017 - Last Review/Update July 28th, 2017
Dynamic splinting systems or devices are used to assist in restoring physical function and are commonly used for treating TMJ. Injury or joint stiffness are diagnoses that may qualify for medically necessity.
If physical therapy has proven ineffective to restore or improve range of motion, mechanical devices are often a next step.
This ...
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 2nd, 2017
Requirements for Physicians Orders for DME/HCPCS
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017
Effective July 1, 2013, certain DME/HCPCS codes require a valid detailed written order prior to delivery. There are very specific rules and requirements requiring medical necessity and orders/prescriptions. It is also required to keep a copy in the patients chart. If billing CMS and commercial payers payers, the DME prescribed ...
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 27th, 2017
Documentation: Face to Face for Home Health Certification
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 27th, 2017 - Last Review/Update August 16th, 2017
As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care.
Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. ...
February 23rd, 2017
Care Plan Oversight Services
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 23rd, 2017 - Last Review/Update August 2nd, 2017
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 ...
February 23rd, 2017
Emergency Preparedness Final Rule
By Wyn Staheli, Director of Research | Published February 23rd, 2017
Compliance has a new standard for emergency preparedness plans. On September 8, 2016, CMS issued the final rule titled “Emergency preparedness requirements for Medicare and Medicaid participating providers and suppliers.” This rule creates emergency preparedness Medicare Conditions of Participation (COPs).
There are specific standards for each of the named types of providers ...
February 21st, 2017
Telehealth Psychiatric Service
By Wyn Staheli, Director of Research | Published February 21st, 2017
Telehealth (also known as telemedicine) is playing an ever increasing roll in the reimbursement process. Internet services continue to expand and many insurance payers/providers are now covering (paying for) telehealth services. Telepsychiatry (providing behavioral health services in a telehealth environment) has been highly successful because video conferencing makes providing psych ...
February 15th, 2017
CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018
By CMS.gov | Published February 15th, 2017
The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients.
February 11th, 2017
Podiatry Class Findings
By Wyn Staheli, Director of Research | Published February 11th, 2017
The following modifiers are required when reporting medically necessary routine foot care services per Medicare guidelines:
Q7: One Class A finding
Q8: Two Class B findings
Q9: One Class B and two Class C findings
Appropriate: With foot care (podiatry) codes to indicate covered foot care
Inapproriate:
With any code not related to foot care
When the foot ...
February 10th, 2017
Beware of Limitations When Using Electrical Stimulation - Ultrasound
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 10th, 2017 - Last Review/Update August 2nd, 2017
Ultrasound is often used to reduce inflammation and improve the flexibility of connective tissue. This is done by applying sound waves to produce heat and/or vibration. Be aware of the many limitations when reporting this code. Be sure to consult your local carrier LCDs and carefully determine the correct code and the ...
February 10th, 2017
Q/A: What is the Proper Code for "Lumbar Decompression?
By ChiroCode | Published February 10th, 2017 - Last Review/Update February 8th, 2019
Q: What is the proper code for "Lumbar Decompression?
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?
February 2nd, 2017
Coverage and/or Medical Necessity for the Use of Hyaluronan or Derivitive
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 2nd, 2017 - Last Review/Update August 2nd, 2017
Verify your local coverage determination and medical necessity requirements for the following codes:
Hyaluronate Polymers (L33432) - Noridian Medicare
J7320 - Hyaluronan or derivitive, genvisc 850, for intra-articular injection, 1 mg
J7321 - Hyaluronan or derivative, hyalgan or supartz, for intra-articular injection, per dose
J7322 - Hyaluronan or derivative, hymovis, for intra-articular injection, 1 mg
J7323 - Hyaluronan or ...
January 24th, 2017
Code Sets - Health Care Provider Taxonomy Code Set Link
By Raquel Shumway | Published January 24th, 2017
Every Provider needs to know their Health Care Provider Taxonomy Codes. The Taxonomy Codes define the provider type, classification, and area of specialization. We have provided a link and instructions to help you locate your code.
January 23rd, 2017
New and Deleted Drug Screen codes for 2017
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 23rd, 2017 - Last Review/Update March 8th, 2017
Deleted Codes for Drug Screening, the following codes are no longer valid for services performed on or after January 01, 2017.
Deleted Codes for 2017
80300
Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (eg, immunoassay) capable of being read by direct optical ...
January 23rd, 2017
Virtual Groups and MIPS
By Wyn Staheli, Director of Research | Published January 23rd, 2017
During the comment period of the MIPS Proposed Rule (Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models), there were some concerns about NPI and TIN usage for MIPS reporting for smaller organizations.
The following statements are from the MIPS Final ...
January 12th, 2017
Sleep Studies: Billing with Reduced Hours
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 12th, 2017 - Last Review/Update August 2nd, 2017
When using codes 95800, 95801, 95806, 95807, 95810, and 95811, and fewer than six hours of recording is performed, you must report the reduced services using modifier 52.
Also, when using 95782 and 95783, and fewer than seven hours of recording is performed, modifier 52 would be appended to the appropriate code.
95805 would require modifier 52 if fewer than four hours of recording is performed.
Medicare recognizes the ...
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) ...
January 2nd, 2017
G-Codes eff Jan 01,2017 for additional payment for Psych - Collaborative Care
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 2nd, 2017 - Last Review/Update July 26th, 2017
Medicare has agreed to make separate payments to physicians and non-physicians for Behavioral Health Integration (BHI) services beginning Jan. 01, 2017.
Any condition new or pre-existing behavioral health or substance use disorders are eligible. Beneficiaries may have comorbid, chronic, or other medical conditions they are being treated for as well.
Using the ...
December 30th, 2016
How APC Payment Rates Are Set
By Brittney Murdock, QCC, CMCS, CPC | Published December 30th, 2016
The payment rates for most separately payable medical and surgical services are determined by multiplying the prospectively established scaled relative weight for the service’s clinical APC by a conversion factor (CF) to arrive at a national unadjusted payment rate for the APC.
December 20th, 2016
ABN FAQs
By | Published December 20th, 2016 - Last Review/Update November 29th, 2017
This handy FAQ addresses the uses and mis-uses of the ABN form.
December 16th, 2016
VACCINE AND VACCINE ADMINISTRATION PAYMENTS UNDER MEDICARE PART D
By Brittney Murdock, QCC, CMCS, CPC | Published December 16th, 2016
Please note: The information in this publication applies only to Medicare Part D; the Prescription Drug Benefit.
Except for vaccines covered under Medicare Part B, Medicare Part D plans cover all commercially available vaccines as long as the vaccine is reasonable and necessary to prevent illness.
Health care professionals (sometimes known as ...
December 15th, 2016
International Classification of Diseases (ICD)-10 Code Updates and Impact to 4th Quarter 2016 Eligible Professional Medicare Quality Programs
By CMS.gov | Published December 15th, 2016
On October 1, 2016, new International Classification of Diseases (ICD)-10-CM and ICD-10-PCS code sets went into effect. Updating of these codes traditionally occurs on an annual basis, however, during the immediate years leading up to the ICD-9 to ICD-10 transition there was an extended freeze to code updates to support...
December 15th, 2016
CMS Announces Additional Opportunities for Clinicians Under the Quality Payment Program
By Brittney Murdock, QCC, CMCS, CPC | Published December 15th, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced more new opportunities for clinicians to join Advanced Alternative Payment Models (APMs) to improve care and earn additional incentive payments under the Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Beginning in January...
December 13th, 2016
Health Risk Assessment
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 13th, 2016
Risk Adjustment models are used to calculate risk scores used in predicting average beneficiaries healthcare expenditures. Currently Medicare Advantage and Prescription Drug programs include a risk adjustment as a component of the bidding and payment process to standardize bids, compare bids, and adjust plan payments. If you are not familiar ...
December 12th, 2016
60 Day Final Rule
By Wyn Staheli, Director of Research | Published December 12th, 2016
Effective March 14, 2016, the CMS Final Rule clarifying the standards for handling
overpayments for both Medicare and Medicaid takes effect. Failure to report and
subsequently return an overpayment within 60 days after the overpayment was
“identified” is a violation of the False Claims Act.
December 6th, 2016
Oral Maxillofacial Prosthesis (A53496)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 6th, 2016 - Last Review/Update August 1st, 2017
Implants, which could be considered dental but are being inserted to secure, attach, or support the maxillofacial prosthesis, will be covered when the prosthesis is to be used secondary to maxillofacial surgery or repair of traumatic injury. Use CPT code 21299 to bill the implants with an explanation of the intended use. ...
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 19th, 2016
Lack of Medical Necessity
By ChiroCode | Published November 19th, 2016 - Last Review/Update March 5th, 2019
(from page 210 in chapter 3.5 of the 2017 DeskBook) One of the biggest problems providers face when audited is that many services are deemed not medically necessary and are routinely denied. Much of the proof falls back on the medical record.
Here are some specific situations as they may ...
October 17th, 2016
CMS Finalizes the New Medicare Quality Payment Program
By ChiroCode | Published October 17th, 2016 - Last Review/Update March 5th, 2019
On October 14, HHS finalized its policy implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively referred to as the Quality Payment Program.
September 30th, 2016
Medicare Condition Code 44
By Jeanette Anderson, CPC, CPMA | Published September 30th, 2016 - Last Review/Update August 17th, 2017
Medicare Condition Code 44 is used when an inpatient admission needs to be changed to outpatient status. There are some instances where a Medicare patient was admitted to the hospital with an inpatient status, but upon review it is deemed more appropriate for the entire encounter to be an outpatient ...
September 17th, 2016
Government Healthcare Programs
By Wyn Staheli, Director of Research | Published September 17th, 2016
The Department of Health and Human Services (HHS) oversees all government health care programs. They are administered by various agencies such as the Centers for Medicare & Medicaid Services (CMS), the Veterans Administration (VA) and even at the state level. Here are the basic government programs:
Medicare
Federal Workers’ Compensation
Military and Veterans
Medicaid
Federal ...
September 9th, 2016
Looking forward to a 9% payment increase for Medicare Part B
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 9th, 2016
What in the world is MACRA, MIPS and APM? More acronyms, rules and payment changes are headed our way. If you are a Medicare Part B provider, you will want to pay special attention.
MACRA- Medicare Access and CHIP Reauthorization Act of 2015
MIPS- Merit-Based Incentive Payment System
APM – Alternative Payment Model ...
September 9th, 2016
CMS offering options for MACRA Participation. You Choose - Be prepared!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 9th, 2016
The most recent Blog Post from CMS has given a new update on The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS states they will allow providers four options of reporting for the first year of the program stating they can pick their pace of participation for the ...
August 23rd, 2016
Smoking and tobacco cessation counseling, covered indications and # of visits
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 23rd, 2016 - Last Review/Update August 2nd, 2017
Nationally Covered Indications:Effective for claims with dates of service on or after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries1. Who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;2. Who are competent and alert at the time that ...
August 18th, 2016
CMS releases new prescription drug cost data
By Find-A-Code | Published August 18th, 2016
Continuing the commitment to greater data transparency, the Centers for Medicare & Medicare Services (CMS) today released privacy-protected data on the prescription drugs that were paid for under the Medicare Part D Prescription Drug Program in 2014. This is the second release of the data on an annual basis, which...
August 16th, 2016
Functional Limitation Reporting Codes and Modifiers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 16th, 2016
The following G-codes are used for reporting on claims for Medicare Part B and must be used with a severity/complexity modifier, the use of G-codes are enforced and required beginning Jan. 01, 2013, claims will be returned or rejected if they do not contain the required functional G-Code/modifier information.
There are ...
August 16th, 2016
2017 ICD-10- CM Gynecology Updates
By Bonnie Schreck | Published August 16th, 2016
The final list of the new ICD-10- CM codes that become effective October 1, 2016 has been released. There are approximately 1600 changes to the code set, making up for the four years the ICD-10- CM codes have not had a complete update. For fiscal year (FY) 2017, updates to...
August 16th, 2016
2017 ICD-10-CM and ICD-10-PCS Code Updates
By | Published August 16th, 2016
The 2017 ICD-10-CM and ICD-10-PCS code updates, including a complete list of code titles, are available on the 2017 ICD-10-CM and GEMs and 2017 ICD-10-PCS and GEMs webpages.
August 10th, 2016
Guidance for the Use of Codes in Physical Medicine - Pub-100
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2016 - Last Review/Update August 4th, 2017
The following provides guidance about the use of codes 96105, 97026, 97150, 97545, 97546, and G0128.
• CPT Codes 96105, 97545, and 97546.
Providers report code 96105, assessment of aphasia with interpretation and report in 1-hour units. This code represents formal evaluation of aphasia with an instrument such as the Boston Diagnostic Aphasia Examination. If this formal assessment is performed during treatment, ...
August 4th, 2016
Medicare’s Readmission Penalties Hit New High
By Jordan Rau | Published August 4th, 2016
The federal government’s readmission penalties on hospitals will reach a new high as Medicare withholds more than half a billion dollars in payments over the next year, records released Tuesday show. The government will punish more than half of the nation’s hospitals — a total of 2,597...
July 29th, 2016
CODING ARTHROSCOPIC KNEE PROCEDURES
By Codapedia | Published July 29th, 2016
Knee Anatomy: The medical compartment includes: Medial Femoral condyle Medial tibial plateau Medial meniscus The lateral compartment includes: Lateral Femoral condyle Lateral tibial plateau Lateral meniscus The Patellofemoral compartment includes: Patella Patellofemoral joint Intercondylar notch of the femur Suprapatellar pouch Trochlea Arthroscopy: Knee arthroscopy allows the physician to visualize the...
July 28th, 2016
E-prescribing pay cuts loom for some in 2014, 2015
By Codapedia | Published July 28th, 2016
Some practices may find 2014 immediately off to the wrong foot when their Medicare payments are reduced by 2 percent for failing to participate successfully in Medicare’s E-prescribing Incentive Program. Unfortunately, at this point successfully claiming an exemption may be the only way to stave off the cut for non-reporters,...
June 28th, 2016
NAMAS - Study the Rules Before Auditing E&M Services by Teaching Physicians
By Find-A-Code | Published June 28th, 2016
If you work for a facility that utilizes residents, then you will need to understand the requirements for reporting teaching physician services. The Office of Inspector General (OIG) has had hospital teaching physician activities on their work plan repeatedly, and therefore it should be on your radar as well to ...
June 27th, 2016
CMS Announces Proposed Payment Changes for Medicare Home Health Agencies for 2017 (CMS-1648-P)
By Brittney Murdock, QCC, CMCS, CPC | Published June 27th, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced proposed changes to the Medicare home health prospective payment system (HH PPS) for calendar year (CY) 2017 that would foster greater efficiency, flexibility, payment accuracy, and improved quality. Approximately 3.4 million beneficiaries received home health services from approximately 11,400 home ...
June 24th, 2016
Study the Rules Before Auditing E&M Services by Teaching Physicians
By Sara San Pedro, CPC, CEMC, CPMA | Published June 24th, 2016 - Last Review/Update August 17th, 2017
If you work for a facility that utilizes residents, then you will need to understand the requirements for reporting teaching physician services. The Office of Inspector General (OIG) has had hospital teaching physician activities on their work plan repeatedly, and therefore it should be on your radar as well to ...
June 23rd, 2016
Medicare Will Use Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting in 2018
By Brittney Murdock, QCC, CMCS, CPC | Published June 23rd, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) released a final rule implementing Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private insurers for laboratory tests. Medicare will use these private insurer ...
June 15th, 2016
Mastering Medicare: When Opting Out is not an Option
By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published June 15th, 2016 - Last Review/Update March 5th, 2019
Unlike MDs and DOs, chiropractors may not opt out of Medicare.
When it comes to Medicare, providers and patients alike feel like beating their heads against the wall. Signing up to be a provider or a patient is confusing, understanding what is covered is confusing and just about the time you think you have it figured out, you receive a notice that suggests you don’t.
The hassles of Medicare certainly validate any sane person questioning whether they should see a Medicare patient, but with the rising number of Medicare patients in the US do you really want to limit your patient base?
June 9th, 2016
CMS Calculations for Average Sales Pricing ASP
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 9th, 2016 - Last Review/Update August 2nd, 2017
Because Drugs are not a part of the Medicare fees schedule, Drug pricing by Medicare is done according to Average Sales pricing (ASP) and is used to pay Part B claims. Average Wholesale pricing was used for part B Medicare payments until 2005, then ASP pricing/payment structure was implemented.
How ASP ...
June 9th, 2016
Pass-Through Payments, how they work and Device Category Codes List
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 9th, 2016 - Last Review/Update August 4th, 2017
If you want to know if a DRUG is a Pass through drug - Find-A-Code has that information on the code information page under FEES and APC Fee information
A pass through payment for a drug is Medicare reimbursement paid in addition to an ASC's facility fee, however, CMS limits the eligibility ...
June 9th, 2016
Mandatory Submission of Staffing Data via PBJ Begins July 1 for Long – Term care facilities
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 9th, 2016
Electronic submission of staffing data through the Payroll-Based Journal (PBJ) is required of all long-term care facilities starting July 1. The last day to submit data for fiscal quarter four (July 1 through September 30) is November 14, 2016. Nursing homes can register now in the PBJ system to prepare:
Obtain ...
June 6th, 2016
Billing, Documentation and Billable Units
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 6th, 2016 - Last Review/Update August 2nd, 2017
Most third-party payers (eg, commercial insurers, Medicare, Medicaid) cover REMICADE® (infliximab) for its approved U .S . Food and Drug Administration indications (see Indications on page 5 of this guide) . However, benefits may vary depending upon a patient’s insurer or specific insurance plan (or “product”) offered by a payer.
When third-party ...
May 27th, 2016
Documentation Criteria: Medicare Physicals
By Jeanette Anderson, CPC, CPMA | Published May 27th, 2016 - Last Review/Update August 16th, 2017
When billing annual Medicare physicals, it's very important to know the status of the patient, determining when they became eligible, and/or if they've seen another provider for any of these services as the initial visit codes are once in a lifetime codes and will be denied if they have already ...
May 9th, 2016
Billing Compound Drugs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 9th, 2016 - Last Review/Update August 4th, 2017
Unclassified HCPCS codes can only be used when there is not a specific HCPCS code available for the drug being billed.
Each NDC associated with an unclassified drug code should be submitted on a separate claim line following the instructions specified in the Manual for Physicians and Providers- Coding and Filing ...
May 9th, 2016
NOC Drug and Biological Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 9th, 2016 - Last Review/Update August 4th, 2017
The following are tips to help you when billing NOC drugs and biologicals, such as J3490, J3590, and J9999. Providers submit NOC codes in the 2400/SV101-2 data element in the 5010 professional claim transaction (837P).
When billing an NOC code, providers are required to provide a description in the 2400/SV101-7 data element. The 5010 ...
May 3rd, 2016
Using the SBIRT
By Wyn Staheli, Director of Research | Published May 3rd, 2016
Screening, Brief Intervention, and Referral to Treatment (SBIRT) services are an effective tool for healthcare providers to identify, reduce, and prevent problematic substance use disorders. Healthcare practices can help their patients and improve their integrated care standards with the proper use of the SBIRT.
May 3rd, 2016
CMS Publishes Final Rule on Fire Safety Requirements for Certain Health Care Facilities
By Brittney Murdock, QCC, CMCS, CPC | Published May 3rd, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced a final rule (https://www.federalregister.gov/public-inspection) to update health care facilities’ fire protection guidelines to improve protections for all Medicare beneficiaries in facilities from fire.
The new guidelines apply to hospitals; long term care (LTC) facilities; critical access hospitals (CAHs); inpatient hospice facilities; ...
May 3rd, 2016
CMS Finalizes its Quality Measure Development Plan
By Kate Goodrich, M.D., M.H.S., Director, Center for Clinical Standards & Quality, CMS | Published May 3rd, 2016
On December 18, 2015, we posted our draft Quality Measure Development Plan, a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Through March 1, 2016, we asked for stakeholder feedback and received responses from 60 individuals ...
May 3rd, 2016
CMS Publishes Final Rule on Fire Safety Requirements for Certain Health Care Facilities
By Brittney Murdock, QCC, CMCS, CPC | Published May 3rd, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced a final rule (https://www.federalregister.gov/public-inspection) to update health care facilities’ fire protection guidelines to improve protections for all Medicare beneficiaries in facilities from fire.
The new guidelines apply to hospitals; long term care (LTC) facilities; critical access hospitals (CAHs); inpatient hospice facilities; ...
April 29th, 2016
Adaptive Behavior Coding
By Wyn Staheli, Director of Research | Published April 29th, 2016 - Last Review/Update April 9th, 2018
Information about Adaptive Behavior Coding for Members.
April 13th, 2016
Telehealth Basics
By Wyn Staheli, Director of Research | Published April 13th, 2016
Telehealth and telemedicine are covered for many payers for services such as consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system.
April 5th, 2016
Voluntary Disclosure - Look Before You Leap
By ChiroCode | Published April 5th, 2016
Occasionally providers are faced with the need to assess the option of making a voluntary disclosure to the government. Here are steps that every provider should consider before disclosing information to the government.
April 4th, 2016
Coverage Criteria and Medical Necessity with Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 4th, 2016 - Last Review/Update August 3rd, 2017
Negative Pressure Wound Therapy (NPWT) is defined as the application of sub-atmospheric pressure to a wound to remove exudate and debris from wounds. NPWT is delivered through an integrated system of a suction pump, separate exudate collection chamber and dressing sets to a qualified wound. In these systems, exudate is ...
April 4th, 2016
Written Order Prior to Delivery (WOPD) is Required for Payment by Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 4th, 2016 - Last Review/Update August 3rd, 2017
For any item to be covered by Medicare, it must 1) be eligible for a defined Medicare benefit category, 2) be reasonable and necessary for the diagnosis or treatment of illness or injury or to improve the functioning of a malformed body member, and 3) meet all other applicable Medicare ...
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 25th, 2016
Auditing Smoking Cessation Services
By John Burns, CPC, CPC-I, CEMC, CPMA | Published March 25th, 2016 - Last Review/Update August 16th, 2017
Most payers do indeed recognize smoking and tobacco cessation services as a covered health insurance benefit. We have found that some providers perform these services without fully understanding the reimbursement opportunities, while others claim such services without adequately documenting to support them. Medicare, for example, will pay for two (2) ...
March 7th, 2016
Discarded Drugs and Biologicals
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 7th, 2016 - Last Review/Update August 3rd, 2017
When a portion of a drug must be discarded, Medicare allows payment for amount administered as well as the discarded portion. Your Medicare carrier may require you to use modifier JW. The JW modifier is to be applied only to the portion discarded. Multi-use vials are not subject to payment for discarded amounts.
Take ...
March 4th, 2016
Medicare Improper Payment Report for Behavioral Health Services (2014)
By Wyn Staheli, Director of Research | Published March 4th, 2016
Medicare Improper Payment Report information regarding Behavioral Health Services
February 25th, 2016
Pricing is for a single shoe or individual inserts
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 25th, 2016
If you are contracted with a payer be sure you recognize that the pricing is for a single shoe or insert.
When billing orthotics it seems to be less confusing to bill two line items, one for the Left - LT and one for the Right Rt.
...
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 23rd, 2016
PRESCRIPTION (ORDER) REQUIREMENTS (Confirm with your Local Payer)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 4th, 2017
All items billed to Medicare require a prescription. An order for each item billed must be signed and dated by the treating physician, kept on file by the supplier, and made available upon request. Items dispensed and/or billed that do not meet these prescription requirements and those below must be ...
February 23rd, 2016
Coverage Criteria and Medical Necessity for a Mobility Device
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 4th, 2017
General Coverage Criteria for a Mobility DeviceAccording to CMS, all of the following basic criteria (A-C) must be met for a power mobility device (K0800-K0898) or a push-rim activated power assist device (E0986) to be covered. Additional coverage criteria for specific devices are listed below.
The beneficiary has a mobility limitation ...
February 23rd, 2016
Billing Reminders - (POV - Power Operated Vehicles) Modifiers, Verification, Delivery time...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 4th, 2017
According to CMS, delivery of the PMD must be within 120 days following completion of the F2F.
Exception: within 6 months from the date of an affirmed ADMC.
• The PMD will be denied if the underlying condition is reversible and length of need is < 3 months.
• The KX modifier ...
February 17th, 2016
Getting Paid When Reporting Unlisted Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 17th, 2016 - Last Review/Update August 4th, 2017
Using unlisted codes can be quite labor intensive, but if you are prepared and understand ahead of time about using unlisted codes you will have a higher success rate of reimbursement.
Verify the payers guidelines - Be sure your code selection it is a payable code; if it is not a payable code ...
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
Message to DME Suppliers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 15th, 2016
The Patient Access and Medicare Protection Act (PAMPA) was recently signed into law on December 28, 2015. Beginning January 1, 2016, the DME fee schedule rates are adjusted to reflect information from the DMEPOS competitive bidding program as required by section 1834(a)(1)(F)(ii) of the Social Security Act. These adjustments are ...
February 15th, 2016
Unified Program Integrity Contractors (UPIC)
By InstaCode Institute | Published February 15th, 2016
CMS is developing a new Unified Program Integrity Contractor (UPIC) program to consolidate Medicare and Medicaid reviews. This consolidation of the Medicaid Integrity Contractors (MICs) and the Medicare Zone Program Integrity Contractors (ZPICs) could relieve some of the overlap and burdens under the current systems.
February 12th, 2016
Behavioral Heath Treatment/Services - Documentation Requirements
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 12th, 2016 - Last Review/Update August 4th, 2017
Reason for referral.
Tests administered, scoring/interpretation, and time involved.
Present evaluation.
Diagnosis (or suspected diagnosis that was the basis for the testing if no mental/neurocognitive illness was found).
Recommendations for interventions, if necessary.
Identity of person performing service.
...
February 1st, 2016
Definitive Diagnoses - To Code or Not To Code
By Bonnie Schreck | Published February 1st, 2016
For inpatient coding, there are times when the diagnosis(es) cannot be established at the time of admit or throughout the course of the admission. In these cases, they are documented in the medical record as “probable,” “suspected,” “likely,” “questionable,” “possible,” or “rule out” conditions. This guideline is true for certain...
February 1st, 2016
Documentation and Billing Practices
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 1st, 2016 - Last Review/Update August 7th, 2017
Prescribed to:
Reduce pain by restricting mobility of the trunk: OR
Facilitate healing following an injury to the spine or related tissue; OR
Otherwise support weak and/or deformed spinal muscles.
Documentation and billing practices be sure you are meeting all the requirements to bill a spinal orthoses.
Spinal Orthoses billed with HPCPCS L0450, L0454, L0621, L0625 and L0628 must be billed with ...
February 1st, 2016
Elastic Garments - Medicare Noncovered
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 1st, 2016 - Last Review/Update August 4th, 2017
According to Noridian, CMS has determined that elastic garments do not meet the statutory definition of a brace because they are not rigid or semi-rigid devices. Therefore, effective for claims with dates of service on or after April 1, 2009, these items will be denied as Medicare noncovered, no benefit category.
This ...
January 29th, 2016
Wound Care & Debridement- Provided by Physician, NPP or as Incident-to Services
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 29th, 2016
Providers must document the medical necessity for all services provided. If there is no documented evidence (e.g., objective measurements) of ongoing significant benefit, then the medical record documentation must provide other clear evidence of medical necessity for treatments. The medical record must also clearly indicate the complexity of skills required ...
January 29th, 2016
Certificate for Provider - Performed Microscopy Procedures
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 29th, 2016
Effective January 19, 1993, a laboratory that holds a certificate for provider-performed microscopy procedures may perform only those tests specified as provider-performed microscopy procedures and waived tests, as described below, and no others.
HCPCS Code Test
Q0111
Wet mounts, including preparations of vaginal, cervical or skin
specimens
Q0112
All potassium hydroxide (KOH)
preparations
Q0113
Pinworm examinations
Q0114
Fern test
Q0115
Post-coital direct, qualitative ...
January 29th, 2016
What is MIPS?
By Wyn Staheli, Director of Research | Published January 29th, 2016
The Merit-Based Incentive Payment System (MIPS) combines PQRS, VM, and EHR into a single Medicare pay-for-performance quality payment system scheduled to begin in 2019.
January 6th, 2016
6 ways to stop filing duplicate Medicare claims - Duplicates could expose your practice to fraud investigation
By | Published January 6th, 2016
Whenever a Medicare Administrative Contractor (MAC) releases a list of the top reasons for claims denials, the list almost never fails to include duplicate claims. When the MAC perceives the claim to be a duplicate, based typically on a match of the patient identifying information, furnishing...
January 6th, 2016
Preventive Medicine Services for Medicare Patients
By Codapedia | Published January 6th, 2016
The most widely known fact about Medicare and preventive medicine is that fee-for-service Medicare does not cover an annual physical exam. This is because in its beginning, Medicare was prohibited from paying for routine services. Over the years, Congress has mandated the payment of some screening...
January 6th, 2016
Pre-op visits: True or False?
By Codapedia | Published January 6th, 2016
Are the following statements true or false? • The PCP cannot be paid to do a pre-op assessment of a Medicare patient prior to surgery because of the new consult rules. • The surgeon can never be paid to do a pre-op visit if s/he...
January 6th, 2016
Reporting Administration Codes with Vaccines
By Codapedia | Published January 6th, 2016
When it comes to billing for vaccines, the rules for reporting administration codes can be tricky. Reporting the right vaccine code alone is not enough to guarantee proper billing. Most billing scenarios allow providers to charge for both the vaccine product and the administration of the vaccine itself. However, there...
January 5th, 2016
CMS Announces: Final Rule on Authorization Process for Certain Durable Medical Equipment
By Brittney Murdock, QCC, CMCS, CPC | Published January 5th, 2016
CMS has established a new prior authorization process for DMEPOS items that are frequently subject to unnecessary utilization. The final rule will create an initial Master list that includes items that meet specific criteria.
Items already on the Master List that are identified by a GAO/OIG, or CERT DME and/or DMEPOS ...
December 21st, 2015
Screening barium enema examinations may be paid as an alternative to a screening colonoscopy (code G0105) examination
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 4th, 2017
According to the Pub-100, screening barium enema examinations may be paid as an alternative to a screening colonoscopy (code G0105) examination. The same frequency parameters for screening colonoscopies (see those codes above) apply. In the case of an individual who is at high risk for colorectal cancer, payment may be made for ...
December 21st, 2015
Colorectal Cancer Screening; Barium Enema; as an Alternative to G0104, Screening Sigmoidoscopy
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 7th, 2017
G0106 - Colorectal Cancer Screening; Barium Enema; as an Alternative to G0104, Screening Sigmoidoscopy Screening barium enema examinations may be paid as an alternative to a screening sigmoidoscopy (code G0104). The same frequency parameters for screening sigmoidoscopies (see those codes above) apply.In the case of an individual aged 50 or over, payment may be ...
December 21st, 2015
Characteristics of High Risk and How Often Test can be Performed
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 7th, 2017
According to Medicares Pub-100, 60 - Colorectal Cancer Screening Ref: AB-03-114;
Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month ...
December 21st, 2015
Service is considered colorectal cancer screening services, age limit, every 48 months
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 7th, 2017
G0104 - Colorectal Cancer Screening; Flexible Sigmoidoscopy
Screening flexible sigmoidoscopies (code G0104) may be paid for beneficiaries who have attained age 50, when performed by a doctor of medicine or osteopathy at the frequencies noted below.For claims with dates of service on or after January 1, 2002, contractors or carriers pay for screening ...
December 21st, 2015
Review Incident - To for Compliance
By Aimee Wilcox, MA CST CCS-P | Published December 21st, 2015
If your organization performs incident-to services, be sure to perform a periodic review of the rules that govern incident to and then compare them to the practices of your providers to ensure they would pass an audit. Here are just a few of the guidelines that should be reviewed; however, ...
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 2nd, 2015
CMS clarifies the ways physician practices can respond to additional documentation requests
By | Published December 2nd, 2015
It’s one of the inevitabilities of running a physician practices that never happens at a good time and seems to rarely go very smoothly. You see an additional documentation request – known as an ADR – from either your Medicare Administrative Contractor (MAC) or one of...
November 24th, 2015
You do not need to change or rewrite your original orders
By Find-A-Code | Published November 24th, 2015
CMS wants to remind you not to change or rewrite your original orders for any service or product due to the change of code sets from ICD-9-CM to ICD-10-CM.
For any type of product or service prior to October 1, 2015, do not change the order, even if it will be ...
November 24th, 2015
Prescription (order) Requirements
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 24th, 2015
Prescription (order) Requirements face-to-face examination is required each time a new prescription for one of the specified items is ordered. A new prescription is required by Medicare:
• For all claims for purchases or initial rentals
• When there is a change in the prescription for the accessory, supply, drug, etc.
• If ...
November 19th, 2015
Not Documented, Not Done: Medicare Myth or Rule?
By | Published November 19th, 2015
After years of unchallenged recitation, the coding community has virtually canonized the phrase “not documented—not done” into coding scripture. But there are good reasons to question whether the now-famous epigram reflects an actual rule or whether it has simply taken on a life of its own like ...
November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY CMS-484 — OXYGEN DME 484.3 - Free
By Find-A-Code | Published November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY CMS-484 — OXYGEN DME 484.3
...
November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY CMS-846 — PNEUMATIC COMPRESSION DEVICES DME 04.04B - Free
By Find-A-Code | Published November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY CMS-846 — PNEUMATIC COMPRESSION DEVICES - DME 04.04B
...
November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY CMS-847 — OSTEOGENESIS STIMULATORS - Free
By Find-A-Code | Published November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY CMS-847 — OSTEOGENESIS STIMULATORS DME 04.04C
...
November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY CMS-848 — TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS) - Free
By Find-A-Code | Published November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY CMS-848 — TRANSCUTANEOUS ELECTRICAL NERVE STIMULATOR (TENS) - DME 06.03B
...
November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY CMS-849 — SEAT LIFT MECHANISMS - Free
By Find-A-Code | Published November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY CMS-849 — SEAT LIFT MECHANISMS - DME 07.03A
...
November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY DME 11.02 CMS-854 — CONTINUATION FORM - Free
By Find-A-Code | Published November 9th, 2015
CERTIFICATE OF MEDICAL NECESSITY CMS-854 — CONTINUATION FORM - DME 11.02
...
November 9th, 2015
DME INFORMATION FORM CMS-10125 — EXTERNAL INFUSION PUMPS - Free
By Find-A-Code | Published November 9th, 2015
DME INFORMATION FORM CMS-10125 — EXTERNAL INFUSION PUMPS - DME 09.03
...
November 9th, 2015
DME INFORMATION FORM CMS-10126 — ENTERAL AND PARENTERAL NUTRITION - Free
By Find-A-Code | Published November 9th, 2015
DME INFORMATION FORM CMS-10126 — ENTERAL AND PARENTERAL NUTRITION - DME 10.03
...
November 9th, 2015
Fee For Service Advance Beneficiary Notice of Noncoverage - Free
By Find-A-Code | Published November 9th, 2015
Fee For Service Advance Beneficiary Notice of Noncoverage
The Advanced Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131, is issued by providers (including independent laboratories, home health agencies, and hospices), physicians, practitioners, and suppliers to Original Medicare (fee for service) beneficiaries in situations where Medicare payment is expected to be denied. Guidelines ...
November 9th, 2015
Medicare Enrollment Application - Durable Medical equipment, prosthetics, orthotics, and Supplies (DMepoS) Suppliers - Free
By Find-A-Code | Published November 9th, 2015
Medicare Enrollment Application Durable Medical equipment, prosthetics, orthotics, and Supplies (DMepoS) Suppliers - CMS-855S
...
November 9th, 2015
Medicare Reconsideration Request Form — 2nd Level of Appeal - Free
By Find-A-Code | Published November 9th, 2015
Medicare Reconsideration Request Form — 2nd Level of Appeal
...
November 9th, 2015
National Supplier Clearinghouse - SUGGESTED TEMPLATES FOR COMPLIANCE WITH CERTAIN SUPPLIER STANDARDS - FREE
By Find-A-Code | Published November 9th, 2015
The attached model forms were created in an effort to educate suppliers regarding certain supplier standards listed in 42 CFR.424.57(c). Please note that these forms are simply templates and suppliers should feel free to create their own forms. Suppliers using their own forms must ensure the forms are capturing and documenting information ...
November 9th, 2015
Electronic Funhttps://panel.findacode.com/my-articles-edit.html?id=27816#page-1ads Transfer (EFT) Authorization Agreement - CMS 588 - Free
By Find-A-Code | Published November 9th, 2015
Electronic Funds Transfer (EFT) Authorization Agreement - CMS 588
...
November 9th, 2015
VPIQ/CSI Enrollment Form - Free
By Find-A-Code | Published November 9th, 2015
Use this form for adding new users, reactivating users, terminating users or adding/deleting PTANs from active IDs in the CSI/VPIQ System.
...
November 9th, 2015
DME MAC Jurisdiction A ASCA Waiver Request Form - Free
By Find-A-Code | Published November 9th, 2015
Submit this form, along with your supporting documentation, when requesting an Administration Simplification Compliance Act (ASCA) waiver which grants the ability to submit paper claims for suppliers in specific circumstances.
...
November 9th, 2015
ADMC Request Form - Free
By Find-A-Code | Published November 9th, 2015
Use this cover sheet when submitting requests for Advance Determination of Medicare Coverage (ADMC).
...
November 9th, 2015
DME Extended Repayment Schedule (ERS) Package - Free
By | Published November 9th, 2015
Use this form when requesting an extended repayment plan.
...
November 9th, 2015
Freedom of Information Act (FOIA) Form - Free
By Find-A-Code | Published November 9th, 2015
Freedom of Information Act (FOIA) Form - Use this form when making a Freedom of Information Act (FOIA) request to NHIC, Corp.
...
November 9th, 2015
Immediate Offset Request Form - Free
By Find-A-Code | Published November 9th, 2015
Immediate Offset Request Form - Use this form when requesting an immediate offset.
...
November 9th, 2015
Medicare Redetermination Request Form
By Find-A-Code | Published November 9th, 2015
Medicare Redetermination Request Form - The Redetermination Request Form is for all DMEPOS suppliers to use when submitting a redetermination request. The form is designed so that users can easily include all of the basic information needed to submit a redetermination request and is valid in all four DME MAC Jurisdictions. A ...
November 9th, 2015
Medicare Redetermination Request Form Checklist - Free
By Find-A-Code | Published November 9th, 2015
Medicare Redetermination Request Form Checklist - Use this checklist for assistance when completing a Redetermination Request Form.
...
November 9th, 2015
Medicare Reopening Request Form - Free
By Find-A-Code | Published November 9th, 2015
Medicare Reopening Request Form - The Reopening Request Form is for all DMEPOS suppliers to use when submitting a Reopening request. The form is designed so that users can easily include all of the basic information needed to submit a Reopening request and is valid in all four DME MAC Jurisdictions. A ...
November 9th, 2015
Medicare Reopening Request Form Checklist - Free
By Find-A-Code | Published November 9th, 2015
Medicare Reopening Request Form Checklist - Use this checklist for assistance when completing a Reopening Request Form.
...
November 9th, 2015
Overpayment Refund Form - Free
By Find-A-Code | Published November 9th, 2015
Overpayment Refund Form - Use this cover sheet when submitting voluntary refunds for an overpayment situation.
...
November 9th, 2015
PMD Prior Authorization Demonstration Coversheet - Free
By Find-A-Code | Published November 9th, 2015
PMD Prior Authorization Demonstration Coversheet - This coversheet is used for items associated with the PMD Prior Authorization Demonstration. More information concerning the PMD Prior Authorization Demonstration can be found on the CMS Web site.
...
November 9th, 2015
PSP E-Authentication Identity Proofing Documentation Form - Free
By Find-A-Code | Published November 9th, 2015
PSP E-Authentication Identity Proofing Documentation Form - This form is used to begin the Provider Services Potral (PSP) enrollment process.
...
November 9th, 2015
PWK Coversheet - Free
By | Published November 9th, 2015
PWK Coversheet - This coversheet is used when sending PWK documentation to the DME MAC contractor.
...
October 19th, 2015
The JW Modifier is Only Applied to the Amount of Drug or Biological that is Discarded
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 19th, 2015 - Last Review/Update August 4th, 2017
According to CMS, local contractors may require the use of the modifier JW to identify unused drug or biologicals from single use vials or single use packages that are appropriately discarded. This modifier, billed on a separate line, will provide payment for the amount of discarded drug or biological.
For example, ...
October 13th, 2015
Pricing Modifier
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 13th, 2015 - Last Review/Update August 7th, 2017
Place the modifiers listed below (except modifiers with an *) to the right of the procedure code in Item 24D on the CMS 1500 claim form or for ANSI X12 4010 electronic claims submission use segment 2-370-SV101-3.
Processing delays can occur for claims submitted without the pricing modifier in the first modifier position. ...
October 8th, 2015
Conditions or Exceptions that might justify coverage of foot care
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 8th, 2015 - Last Review/Update August 7th, 2017
When using G0127 keep in mind routine foot/nail care is generally excluded from coverage under Medicare, however there are some exceptions:
Click here to read the entire article
Although not intended as a comprehensive list, the following metabolic, neurologic,and peripheral vascular diseases (with synonyms in parentheses) most commonly represent the underlying conditions that might ...
September 25th, 2015
Coordination of Benefits
By Christine Taxin | Published September 25th, 2015
Coordination of benefits, (COB) is a clause in most group policies, which is in place to minimize the over-payment or duplicate payment of claims. COB applies to patients covered by more than one insurance plan and limits the amount paid by each plan.
With the COB clause the payments made by ...
September 25th, 2015
Bone Mass Measurements (BMMs)
By Find-A-Code | Published September 25th, 2015
Listed is a summary of the revisions and additions to Chapter 13 of the Medicare Claims Processing Manual and Chapter 15 of the Medicare Benefit Policy Manual.
CHAPTER 13
Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee Schedule final rule expanded the number of ...
September 21st, 2015
Documentation and Reimbursement for Testing
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 21st, 2015 - Last Review/Update August 7th, 2017
The medical record must contain documentation that the testing is expected to influence treatment of the condition toward which the testing is directed. The laboratory or billing provider must have on file the physician requisition which sets forth the diagnosis or condition that warrants the test(s).
TC - Technical component Modifier may be ...
September 11th, 2015
Medicare Makes Moderate Sedation Payable
By Find-A-Code | Published September 11th, 2015
Medicare Makes Moderate Sedation Payable
Christine Taxin
Should your primary care physicians ever find cause to perform moderate sedation, you’ll be interested in a new Medicare policy that may make it payable as of Oct. 1. Medicare Pub. 100-04 Transmittal 1324 finally makes Medicare policy consistent with the fee schedule pricing for ...
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
Summary of Adjustments to Fee Schedule Computations (Rev.1931, Issued:03-12-10)
By | Published August 19th, 2015
For services prior to January 1, 1994, B/MACs computed the fee schedule amount for every service. Through 1995, the fee schedule amount is the transition fee schedule amount. For services after 1995, CMS computes and provides the fee schedule amount for every service discussed below. Certain adjustments are made in ...
August 19th, 2015
Chiropractic Listed as Focal Point in 2015 OIG Work Plan
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published August 19th, 2015 - Last Review/Update January 30th, 2017
With the recent release of the 2015 OIG Work Plan, many providers and facilities are reviewing the content to learn which areas of interest pertaining to their specialty will be points of interest for federal auditing programs for the 2015 Fiscal Year. The information contained in this Work Plan addresses the ...
August 19th, 2015
First Physician Fee Schedule Proposed Rule Since SGR Repeal
By Wyn Staheli, Director of Research | Published August 19th, 2015
Even though the SGR has been repealed, providers still need to be aware of annual fee revisions by CMS. On July 8, 2015, CMS announced their first proposed Medicare Physician Fee Schedule (MFPS) since the SGR repeal. As in years past, there will continue to be reviews of the Relative Value ...
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
Opting out of Medicare Electing to Order/Certify Items and Services to Medicare Beneficiaries
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2015
Physicians and practitioners who do not wish to enroll in the Medicare program may “opt-out” of Medicare. This means that neither the physician, nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket and neither party is reimbursed by Medicare. A private ...
August 10th, 2015
Adjunctive (Add-On) Codes
By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017
Stop losing hard-earned dollars. Too often, dollars are left on the table at billing time. Adjunctive codes for associated services should be added when they are appropriate. Here are a few examples of coding that are often overlooked.
97014 & 97032 Electrical Stimulation Supplies
According to the Relative Value Update Committee (RUC), ...
August 7th, 2015
TMJ Medical Necesity and Documentation- Aetna
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 7th, 2015 - Last Review/Update August 7th, 2017
Notes: Most Aetna HMO plans exclude coverage for treatment of temporomandibular disorders (TMD) and temporomandibular joint (TMJ) dysfunction
For plans that cover treatment of TMD and TMJ dysfunction, requests for TMJ surgery require review by Aetna's Oral and Maxillofacial Surgery patient management unit. Reviews must include submission of a problem-specific history ...
August 7th, 2015
Reimbursed on a Daily Basis /Modifiers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 7th, 2015 - Last Review/Update August 7th, 2017
HCPCS codes E0935 (Continuous passive motion exercise device for use on knee only), and E0936 (Continuous passive motion exercise device for use other than knee) are reimbursed on a daily basis consistent with CMS guidelines.
The following HCPCS codes are also reimbursed on a daily basis:
E0193 -Powered air flotation bed (low air loss therapy)
E0194 -Air fluidized bed
E0277 –Powered ...
August 3rd, 2015
Notice of Election (NOE) - Form CMS - 1450 (Rev. 3118)
By Find-A-Code | Published August 3rd, 2015
When a Medicare beneficiary elects hospice services, hospices must complete form locators identified in section 20.1.2 for the Uniform (Institutional Provider) Bill (Form CMS-1450), which is an election notice.
In addition, the hospice must complete the Form CMS-1450 when the election is for a patient who has changed an election from one ...
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 20th, 2015
Formats for Submitting Claims to Medicare - Electronic Submission Requirements
By Find-A-Code | Published July 20th, 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 Administrative Simplification Compliance Act (ASCA) requires that claims be submitted to Medicare electronically unless certain exceptions are met. In addition, the Health Insurance ...
July 20th, 2015
HIPAA Standards for Claims
By | Published July 20th, 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.
Claims sent electronically to Medicare must abide by the HIPAA standards ...
July 20th, 2015
Payment Jurisdiction Among A/B MACs (B) for Services Paid Under the Physician Fee Schedule and Anesthesia Services (Rev. 3086)
By Find-A-Code | Published July 20th, 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 jurisdiction for processing a request for payment for services paid under the Medicare Physician Fee Schedule (MPFS) and for anesthesia services is ...
July 20th, 2015
Payment Jurisdiction for Services Subject to the Anti-Markup Payment Limitation
By Find-A-Code | Published July 20th, 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)
Diagnostic tests and their interpretations are paid on the MPFS. Therefore, they are subject ...
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
Provider Change of Ownership (CHOW) (Rev. 861, Issued: 02-17-06)
By Find-A-Code | Published July 17th, 2015
Providers (as defined in 1861(u) of the Act, and institutional suppliers such as RHCs) that undergo a change in their ownership structure are required to notify CMS concerning the identity of the old and new owners. They are also required to inform CMS on how they will organize the new ...
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
Dentists: Prescriptions and Referring to other providers with Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 13th, 2015
Are you aware you must be participating with Medicare Part D to be eligible to prescribe medication's to patients that have Medicare? If you are not participating, your patients will not be able to fill their prescriptions.
You may also enroll to become an ordering and referring Medicare provider. You will not be recognized ...
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 10th, 2015
Coding Requirements for Specimen Collection (Rev. 3056, 12-01-14)
By Jared Staheli | Published July 10th, 2015
The following HCPCS codes and terminology must be used:
• 36415 – Collection of venous blood by venipuncture.
• G0471 – Collection of venous blood by venipuncture or urine sample by catheterization from an individual in a skilled nursing facility (SNF) or by a laboratory on behalf of a home health agency ...
July 10th, 2015
Certificate for Provider-Performed Microscopy Procedures (Rev. 865, 07-03-06)
By Jared Staheli | Published July 10th, 2015
Effective January 19, 1993, a laboratory that holds a certificate for provider-performed microscopy procedures may perform only those tests specified as provider-performed microscopy procedures and waived tests, as described below, and no others.
HCPCS Code
Test
Q0111
Wet mounts, including preparations of vaginal, cervical or skin specimens
Q0112
All potassium hydroxide (KOH) preparations
Q0113
Pinworm examinations
Q0114
Fern test
Q0115
Post-coital direct, ...
July 10th, 2015
Certificate of Waiver (Rev. 1652, 01-05-09) - CLIA
By Jared Staheli | Published July 10th, 2015
Effective September 1, 1992, all laboratory testing sites (except as provided in 42 CFR 493.3(b)) must have either a CLIA certificate of waiver, certificate for providerperformed microscopy procedures, certificate of registration, certificate of compliance, or certificate of accreditation to legally perform clinical laboratory testing on specimens from individuals in the ...
July 10th, 2015
HCPCS Subject To and Excluded From CLIA Edits (Rev. 865, 07-03-06)
By Jared Staheli | Published July 10th, 2015
At this time, all claims submitted for laboratory tests subject to CLIA are edited at the CLIA certificate level. However, the HCPCS codes that are considered a laboratory test under CLIA change each year. The CMS identifies the new HCPCS (non-waived, nonprovider-performed procedure) codes, including any modifiers that are subject ...
July 10th, 2015
National Minimum Payment Amounts for Cervical or Vaginal Smear Clinical Laboratory Tests (Rev. 1, 10-01-03)
By Jared Staheli | Published July 10th, 2015
For cervical or vaginal smear clinical laboratory tests, payment is the lesser of the local fee or the national limitation amount, but not less than the national minimum payment amount (NMPA). However, in no case may payment for these tests exceed actual charges. The Part B deductible and coinsurance do ...
July 9th, 2015
Hospital Outpatient Payment Under OPPS for New, Unclassified Drugs and Biologicals After FDA Approval But Before Assignment of a Product-Specific Drug or Biological HCPCS Code (Rev. 3085)
By Jared Staheli | Published July 9th, 2015
Section 621(a) of the MMA amends Section 1833(t) of the Social Security Act by adding paragraph (15), Payment for New Drugs and Biologicals Until HCPCS Code Assigned. Under this provision, payment for an outpatient drug or biological that is furnished as part of covered outpatient department services for which a ...
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
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
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
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
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
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
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
Pharmacy Supplying Fee and Inhalation Drug Dispensing Fee (Rev. 754, 01-03-06)
By Jared Staheli | Published July 9th, 2015
Section 303(e) (2) of the MMA implements a supplying fee for immunosuppressive drugs, oral anti-cancer chemotherapeutic drugs, and oral anti-emetic drugs used as part of an anti-cancer chemotherapeutic regimen. Effective January 1, 2005, Medicare paid a separately billable supplying fee of $24.00 to a pharmacy, dialysis facility in the State ...
July 9th, 2015
Reporting of Hematocrit and/or Hemoglobin Levels (Rev. 1412, 04-07-08)
By Jared Staheli | Published July 9th, 2015
Effective January 1, 2008, the following claims must report the most recent hematocrit or hemoglobin reading:
1. All claims billing for the administration of an ESA (HCPCS J0881, J0882, J0885, J0886 and Q4081).
2. All claims for the administration of a Part B anti-anemia drug (other than ESAs) used in the treatment ...
July 9th, 2015
Required Modifiers for ESAs Administered to Non-ESRD Patients (Rev. 1412, 04-07-08)
By Jared Staheli | Published July 9th, 2015
Effective January 1, 2008, all non-ESRD claims billing HCPCS J0881 and J0885 must begin reporting one of the following modifiers:
EA: ESA, anemia, chemo-induced
EB: ESA, anemia, radio-induced
EC: ESA, anemia, non-chemo/radio
Institutional claims that do not report one of the above modifiers will be returned to the provider.
Professional claims that are billed without ...
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 ESAs Administered to Cancer Patients for Anti-Anemia Therapy (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 9th, 2015
The national coverage determination (NCD) titled, “The Use of ESAs in Cancer and Other Neoplastic Conditions” lists coverage criteria for the use of ESAs in patients who have cancer and experience anemia as a result of chemotherapy or as a result of the cancer itself. The full NCD can be ...
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 9th, 2015
Claims Processing Rules for Hospital Outpatient Billing and Payment - HCPCS Codes Replacements (Rev. 2903, 04-07-14)
By Jared Staheli | Published July 9th, 2015
The HCPCS code list of retired codes and new HCPCS codes reported under the hospital OPPS is published quarterly via Recurring Update Notification. The latest payment rates associated with each APC number may be found in the OPPS PRICER file available on the CMS Web site, as well as in ...
July 8th, 2015
DMEPOS - Repair Labor Billing and Payment Policy
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 8th, 2015
The following table contains repair units of service allowances for commonly repaired items billed under HCPCS code K0739 (Repair or Non-routine Service for Durable Medical Equipment Other than Oxygen Equipment Requiring the Skill of a Technician, Labor Component, Per 15 Minutes). This applies to non-rented and out-of-warranty items.
When billing for ...
July 8th, 2015
Single Drug Pricer (SDP) (Rev. 397, 01-03-05)
By Jared Staheli | Published July 8th, 2015
Effective January 1, 2003, contractors pay drug claims on the basis of the prices shown on the SDP files, if present.
On a quarterly basis, CMS furnishes three SDP files to all FIs, carriers, and ROs except regional home health intermediaries (RHHIs) and durable medical equipment regional carriers (DMERCs), as follows:
1. ...
July 8th, 2015
Assignment Required for Drugs and Biologicals (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
A. Local Carriers
Under §114 of the Benefits Improvement Act of 2000, effective for claims with dates of service on or after February 1, 2001, payment for any drug or biological covered under Part B of Medicare may be made only on an assignment-related basis. Therefore, no charge or bill may ...
July 8th, 2015
Claims Processing Requirements - General (Rev. 3085, Implementation: Upon Implementation of ICD- 10)
By Jared Staheli | Published July 8th, 2015
A/B MACs (B) are billed with the ASC X12 837 professional claim format or, if approved, with the paper form CMS-1500. A/B MACs (A) are billed with the ASC X12 837 institutional claim format or, if approved, with the paper Form CMS-1450.
See Chapters 24, 25 and 26 for detailed claims ...
July 8th, 2015
HCPCS Service Coding for Oral Cancer Drugs (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
The following codes may be used for drugs other than Prodrugs, when covered:
Generic/Chemical Name
How Supplied
HCPCS
Busulfan
2 mg/ORAL
J8510
Capecitabine
150mg/ORAL
J8520
Capecitabine
500mg/ORAL
J8521
Methotrexate
2.5 mg/ORAL
J8610
Cyclophosphamide *
25 mg/ORAL
J8530
Cyclophosphamide *
(Treat 50 mg. as 2 units
50 mg/ORAL
J8530
Etoposide
50 mg/ORAL
J8560
Melphalan
2 mg/ORAL
J8600
Prescription Drug chemotherapeutic NOC
ORAL
J8999
Each tablet or capsule is equal to one unit, except for 50 mg./ORAL of cyclophosphamide (J8530), which is shown as ...
July 8th, 2015
HCPCS and NDC Reporting for Prodrugs (Rev. 136, 04-09-04)
By Jared Staheli | Published July 8th, 2015
FI claims
For oral anti-cancer Prodrugs HCPCS code J8999 is reported with revenue code 0636.
DMERC claims
The supplier reports the NDC code on the claim. The DMERC converts the NDC code to a “WW” HCPCS code for CWF. As new “WW” codes are established for oral anticancer drugs they will be ...
July 8th, 2015
Oral Anti-Emetic Drugs Used as Full Replacement for Intravenous Anti-Emetic Drugs as Part of a Cancer Chemotherapeutic Regimen (Rev. 2931, 07-07-14)
By Jared Staheli | Published July 8th, 2015
See the Medicare Benefit Policy Manual, Chapter 15, and the National Coverage Determination (NCD) Manual, Section 110.18, for detailed coverage requirements.
Effective for dates of service on or after January 1, 1998, Medicare Part B (including (institutional claims processed by Part A Medicare Administrative Contractors (MACs) and physician/supplier claims processed by ...
July 8th, 2015
HCPCS Codes for Oral Anti-Emetic Drugs (Rev. 3085, Effective: Upon Implementation of ICD-10)
By Jared Staheli | Published July 8th, 2015
The physician/supplier bills for these drugs with the ASC X12 837 professional claim format, or if approved, with the paper form CMS-1500. The facility bills with the ASC X12 837 institutional claim format, or if approved, with the paper Form CMS-1450. The following HCPCS codes are assigned:
Code
Description
J8501
APREPITANT, oral, 5 mg ...
July 8th, 2015
Claims Processing Jurisdiction for Oral Anti-Emetic Drugs (Rev. 2931, 07-07-14)
By Jared Staheli | Published July 8th, 2015
The following chart shows which drugs are billed to the A/B MAC, or carrier and which drugs are billed to the DME MAC.
Per the Balanced Budget Act of 1997, effective for claims with dates of service on or after January 1, 1998, the claims processing jurisdiction rules in Chart 1 ...
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
Policy for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11)
By Jared Staheli | Published July 7th, 2015
Claims with dates of service on and after October 14, 2011, the Centers for Medicare & Medicaid Services (CMS) will cover annual alcohol misuse screening (HCPCS code G0442) consisting of 1 screening session, and for those that screen positive, up to 4 brief, face-to-face behavioral counseling sessions (HCPCS code G0443) ...
July 7th, 2015
Institutional Billing Requirements for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 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 alcohol misuse screening, 15 minutes, G0442, and brief, face-to-face behavioral counseling for alcohol misuse, 15 minutes, G0443 for:
• Rural Health Clinics (RHCs) - type of bill (TOB) 71X only – based on ...
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
Claim Adjustment Reason Codes, Remittance Advice Remark Codes, Group Codes, and Medicare Summary Notice Messages for Alcohol Screening and Behavioral Counseling Interventions (Rev. 2433, 10-14-11)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for alcohol misuse screening and alcohol misuse behavioral counseling sessions:
• For RHC and FQHC claims that contain screening for alcohol misuse HCPCS code G0442 ...
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
CARCs, RARCs, Group Codes, and MSN Messages for Screening for Depression in Adults (Rev. 2431, 10-14-11)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the appropriate CARC, RARC, group codes, or MSN messages when denying payment for annual depression screening in adults:
• For RHCs and FQHCs when screening for depression, HCPCS code G0444, with another encounter/visit with the same line-item date of service, use group code CO and :
o CARC 97 ...
July 7th, 2015
Policy for Intensive Behavioral Therapy for Obesity (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
For services furnished on or after November 29, 2011, Medicare will cover Intensive Behavioral Therapy for Obesity. Medicare beneficiaries with obesity (BMI ≥30 kg/m2 ) who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other ...
July 7th, 2015
Institutional Billing Requirements for Policy for Intensive Behavioral Therapy for Obesity (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
Effective for claims with dates of service on and after November 29, 2011, providers may use the following types of bill (TOB) when submitting HCPCS code G0447: 13x, 71X, 77X, or 85X. Service line items on other TOBs shall be denied.
Effective for claims with dates of service on and after ...
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
Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages for Policy for Intensive Behavioral Therapy (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for obesity counseling sessions:
• Denying services submitted on a TOB other than 13X and 85X:
CARC 171 – Payment is denied when performed by this ...
July 7th, 2015
Screening for Hepatitis C Virus (HCV) (Rev. 3215, 06-02-14)
By Jared Staheli | Published July 7th, 2015
Effective for services furnished on or after June 2, 2014, Medicare covers screening for hepatitis C Virus (HCV) with the appropriate U.S. Food and Drug Administration (FDA) approved/cleared laboratory tests, used consistent with FDA-approved labeling and in compliance with the Clinical Laboratory Improvement Act regulations, when ordered by the beneficiary’s ...
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 7th, 2015
Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages for Screening for Hepatitis C Virus (HCV) (Rev. 3215, 01-05-15)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for HCV screening, HCPCS G0472:
• Denying services submitted on a TOB other than 13X, 71X, 77X, or 85X:
CARC 170 - Payment is denied when ...
July 7th, 2015
Payment Allowance Limit for Drugs and Biologicals Not Paid on a Cost or Prospective Payment Basis (Rev. 131, 03-26-04)
By Jared Staheli | Published July 7th, 2015
Prior to January 1, 2004, drugs and biologicals not paid on cost or prospective payment are paid based on the lower of the billed charge or 95 percent of the average wholesale price (AWP) as reflected in published sources (e.g., Red Book, Price Alert, etc.). Examples of drugs that are ...
July 6th, 2015
Healthcare Common Procedure Coding System (HCPCS) Coding for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
The HCPCS codes listed below were developed for the IPPE benefit effective January 1, 2005, for individuals whose initial enrollment is on or after January 1, 2005.
G0344: Initial preventive physical examination; face-to-face visit, services limited to new beneficiary during the first 6 months of Medicare enrollment
Short Descriptor: Initial ...
July 6th, 2015
A/B Medicare Administrative Contractor (MAC) and Contractor Billing Requirements for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service on and after January 1, 2005, through December 31, 2008, contractors shall recognize the HCPCS codes G0344, G0366, G0367, and G0368 shown above in §80.1 for an IPPE. The type of service (TOS) for each of these codes is as follows:
G0344: TOS = 1
G0366: TOS ...
July 6th, 2015
Coinsurance and Deductible for the IPPE (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
The Medicare deductible and coinsurance apply for the IPPE provided before January 1, 2009.
The Medicare deductible is waived effective for the IPPE provided on or after January 1, 2009. Coinsurance continues to apply for the IPPE provided on or after January 1, 2009.
As a result of the Affordable Care Act, ...
July 6th, 2015
Medicare Summary Notices (MSNs) for the IPPE (Rev. 1615, 01-05-09)
By Jared Staheli | Published July 6th, 2015
When denying additional claims for G0344, G0366, G0367 and G0368, contractors shall use MSN 18.22 - This service was denied because Medicare only covers the one-time initial preventive physical exam with an electrocardiogram within the first 6 months that you have Part B coverage, and only if that coverage begins ...
July 6th, 2015
HCPCS Code for Ultrasound Screening for Abdominal Aortic Aneurysm (Rev. 1113, 01-02-07)
By Jared Staheli | Published July 6th, 2015
Effective for services furnished on or after January 1, 2007, the following code, modifiers, and type of service (TOS) are used for AAA screening services:
G0389: Ultrasound, B-scan and or real time with image documentation; for abdominal aortic aneurysm (AAA) screening
Short Descriptor: Ultrasound exam AAA screen
Modifiers: TC, 26
TOS: 4
...
July 6th, 2015
Advance Beneficiary Notice for Ultrasound Screening for Abdominal Aortic Aneurysm (Rev. 1113, 01-02-07)
By Jared Staheli | Published July 6th, 2015
Medicare contractors will deny an AAA screening service billed more than once in a beneficiary’s lifetime.
If a second G0389 is billed for AAA for the same beneficiary or if any of the other statutory criteria for coverage listed in section 1861(s)(2)(AA) of the Social Security Act are not met, the ...
July 6th, 2015
Coding and Payment of DSMT Services (Rev. 1255, 07-02-07)
By Jared Staheli | Published July 6th, 2015
The following HCPCS codes are used to report DSMT:
• G0108 - Diabetes outpatient self-management training services, individual, per 30 minutes.
• G0109 - Diabetes outpatient self-management training services, group session (2 or more), per 30 minutes.
The type of service for these codes is 1.
Payment to physicians and providers for outpatient DSMT ...
July 6th, 2015
Healthcare Common Procedure Coding System (HCPCS) for HIV Screening Tests (Rev. 2199, 07-06-10)
By Jared Staheli | Published July 6th, 2015
Effective for claims with dates of service on and after December 8, 2009, implemented with the April 5, 2010, IOCE, the following HCPCS codes are to be billed for HIV screening:
• G0432- Infectious agent antibody detection by enzyme immunoassay (EIA) technique, HIV-1 and/or HIV-2, screening,
• G0433 - Infectious agent antibody ...
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
Healthcare Common Procedure Coding System (HCPCS) Coding for the AWV (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
The HCPCS codes listed below were developed for the AWV benefit effective January 1, 2011, for individuals whose initial enrollment is on or after January 1, 2011.
G0438 - Annual wellness visit; includes a personalized prevention plan of service (PPPS); first visit
G0439 – Annual wellness visit; includes a personalized prevention plan ...
July 6th, 2015
A/B Medicare Administrative Contractor (MAC) and Carrier Billing Requirements for the AWV (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Effective for dates of service on and after January 1, 2011, contractors shall recognize HCPCS codes G0438 and G0439 shown above in section 140.1 for billing AWVs. The type of service (TOS) for each of the new codes is 1. AWV services are paid under the Medicare Physician Fee Schedule ...
July 6th, 2015
Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Advance Beneficiary Notices (ABNs) for the AWV (Rev. 2159, 04-04-11)
By Jared Staheli | Published July 6th, 2015
Messages for Carriers, FIs, and A/B MACs:
When paying claims for an AWV, contractors shall use the following Medicare Summary Notices (MSNs):
MSN: 18.25: “Your Annual Wellness Visit has been approved. You will qualify for another Annual Wellness Visit 12 months after the date of this visit.”
Spanish Version “Su Visita Anual de ...
July 6th, 2015
Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Coding for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
The CMS has created two new G codes for billing for tobacco cessation counseling services to prevent tobacco use for those individuals who use tobacco but do not have signs or symptoms of tobacco-related disease. These are in addition to the two CPT codes 99406 and 99407 that currently are ...
July 6th, 2015
Carrier Billing Requirements for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
Carriers shall pay for counseling to prevent tobacco use services billed with code G0436 or G0437 for dates of service on or after January 1, 2011. Carriers shall pay for counseling services billed with code 99199 for dates of service performed on or after August 25, 2010 through December 31, ...
July 6th, 2015
Fiscal Intermediary (FI) Billing Requirements for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
The FIs shall pay for counseling to prevent tobacco use services with codes G0436 and G0437 for dates of service on or after January 1, 2011. FIs shall pay for counseling services billed with code 99199 for dates of service performed on or after August 25, 2010, through December 31, ...
July 6th, 2015
Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Group Codes for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
When denying claims for counseling to prevent tobacco use services submitted without diagnosis codes 305.1 or V15.82, contractors shall use the following messages:
MSN 15.4: The information provided does not support the need for this service or item.
MSN Spanish Version: La informaciónproporcionada no confirma la necesidadparaesteservicio o artículo
RARC M64 - Missing/incomplete/invalid ...
July 6th, 2015
Coding Requirements for IBT for CVD Furnished on or After November 8, 2011 (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
The following is the applicable Healthcare Procedural Coding System (HCPCS) code for IBT for CVD:
G0446: Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes
Contractors shall not apply deductibles or coinsurance to claim lines containing HCPCS code G0446.
...
July 6th, 2015
Correct Place of Service (POS) Codes for IBT for CVD on Professional Claims (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
Contractors shall pay for IBT CVD, G0446 only when services are provided at the following POS:
11- Physician’s Office
22-Outpatient Hospital
49- Independent Clinic
72-Rural Health Clinic
Claims not submitted with one of the POS codes above will be denied.
The following messages shall be used when Medicare contractors deny professional claims for incorrect POS:
Claim Adjustment ...
July 6th, 2015
Provider Specialty Edits for IBT for CVD on Professional Claims (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
Contractors shall pay claims for HCPCS code G0446 only when services are submitted by the following provider specialty types found on the provider’s enrollment record:
01= General Practice
08 = Family Practice
11= Internal Medicine
16 = Obstetrics/Gynecology
37= Pediatric Medicine
38 = Geriatric Medicine
42= Certified Nurse Midwife
50 = Nurse Practitioner
89 = Certified Clinical Nurse Specialist
97= ...
July 6th, 2015
Correct Types of Bill (TOB) for IBT for CVD on Institutional Claims (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
Effective for claims with dates of service on and after November 8, 2011, the following types of bill (TOB) may be used for IBT for CVD: 13X, 71X, 77X, or 85X. All other TOB codes shall be denied.
The following messages shall be used when Medicare contractors deny claims for G0446 ...
July 6th, 2015
Frequency Edits for IBT for CVD Claims (Rev. 2432, 11-08-11)
By Jared Staheli | Published July 6th, 2015
Contractors shall allow claims for G0446 no more than once in a 12-month period.
NOTE: 11 full months must elapse following the month in which the last G0446 IBT for CVD took place.
Contractors shall deny claims IBT for CVD claims that exceed one (1) visit every 12 months.
Contractors shall allow one ...
July 6th, 2015
Healthcare Common Procedure Coding System (HCPCS) Codes for Screening for STIs and HIBC to Prevent STIs (Rev. 2476, 02-27-12)
By Jared Staheli | Published July 6th, 2015
Effective for claims with dates of service on and after November 8, 2011, the claims processing instructions for payment of screening tests for STI will apply to the following HCPCS codes:
• Chlamydia: 86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810, 87800 (used for combined chlamydia and gonorrhea testing)
• Gonorrhea: 87590, ...
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 ...
July 5th, 2015
Payment for Colorectal Cancer Screening (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 5th, 2015
Payment is under the MPFS except as follows:
• Fecal occult blood tests (82270* (G0107*) and G0328) are paid under the clinical diagnostic lab fee schedule except reasonable cost is paid to all non-OPPS hospitals, including CAHs, but not IHS hospitals billing on TOB 83x. IHS hospitals billing on TOB 83x ...
July 5th, 2015
Deductible and Coinsurance for Colorectal Cancer Screening (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 5th, 2015
There is no deductible and no coinsurance or copayment for the fecal occult blood tests (G0107 and G0328), flexible sigmoidoscopy (G0104), colonoscopy on individual at high risk (G0105), and colonoscopy on individual not meeting criteria of high risk (G0121). When a screening colonoscopy becomes a diagnostic colonoscopy anesthesia code 00810 ...
July 5th, 2015
HCPCS Codes, Frequency Requirements, and Age Requirements (If Applicable) - Colorectal Cancer Screening (Rev. 3096, 11-18-14)
By Jared Staheli | Published July 5th, 2015
Effective for services furnished on or after January 1, 1998, the following codes are used for colorectal cancer screening services:
• 82270* (G0107*) - Colorectal cancer screening; fecal-occult blood tests, 1-3 simultaneous determinations;
• G0104 - Colorectal cancer screening; flexible sigmoidoscopy;
• G0105 - Colorectal cancer screening; colonoscopy on individual at high risk;
• ...
July 5th, 2015
Common Working Files (CWF) Edits for Colorectal Cancer Screening (Rev. 1062, 01-02-07)
By Jared Staheli | Published July 5th, 2015
Effective for dates of service January 1, 1998, and later, CWF will edit all colorectal screening claims for age and frequency standards. The CWF will also edit FI claims for valid procedure codes (G0104, G0105, G0106, 82270* (G0107*), G0120, G0121, G0122, and G0328) and for valid bill types. The CWF ...
July 5th, 2015
Ambulatory Surgical Center (ASC) Facility Fee for Colorectal Cancer Screening (Rev. 1160, 07-02-07)
By Jared Staheli | Published July 5th, 2015
CPT code 45378, which is used to code a diagnostic colonoscopy, is on the list of procedures approved by Medicare for payment of an ambulatory surgical center facility under §1833(I) of the Act. CPT code 45378 is currently assigned to ASC payment group 2. Code G0105, colorectal cancer screening; colonoscopy ...
July 5th, 2015
Billing Requirements for Claims Submitted to FIs for Colorectal Cancer Screening (Rev. 1953, 10-04-10)
By Jared Staheli | Published July 5th, 2015
Follow the general bill review instructions in Chapter 25. Hospitals use the ANSI X12N 837I to bill the FI or on the hardcopy Form CMS-1450. Hospitals bill revenue codes and HCPCS codes as follows:
Screening Test/Procedure
Revenue Code
HCPCS Code
TOB
Fecal Occult blood test
030X
82270***
(G0107***),
G0328
12X, 13X,
14X**, 22X, 23X,
83X, 85X
Barium enema
032X
G0106,
G0120,
G0122
12X, 13X,
22X, 23X,
85X****
Flexible Sigmoidoscopy
*
G0104
12X, 13X,
22X, 23X,
83X, ...
July 5th, 2015
MSN Messages for Colorectal Cancer Screening (Rev. 1062, 01-02-07)
By Jared Staheli | Published July 5th, 2015
The following MSN messages are used (See Chapter 21 for the Spanish versions of these messages):
A. If a claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a barium enema is being denied because of the age of the beneficiary, MSN message 18.13 is used.
This service is ...
July 5th, 2015
Remittance Advice Notices for Colorectal Cancer Screening (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
All messages refer to ANSI X12N 835 coding.
A. If the claim for a screening fecal-occult blood test, a screening flexible sigmoidoscopy, or a screening barium enema is being denied because the patient is less than 50 years of age, use:
• Claim adjustment reason code 6 “the procedure code is inconsistent ...
July 5th, 2015
HCPCS and Diagnosis Coding for Glaucoma Screening Services (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
The following HCPCS codes should be reported when billing for screening glaucoma services:
G0117 - Glaucoma screening for high-risk patients furnished by an optometrist (physician for carrier) or ophthalmologist.
G0118 - Glaucoma screening for high-risk patients furnished under the direct supervision of an optometrist (physician for carrier) or ophthalmologist.
The carrier claims type ...
July 5th, 2015
Special Billing Instructions for RHCs and FQHCs for Glaucoma Screening Services (Rev. 371, 04-04-05)
By Jared Staheli | Published July 5th, 2015
Screening glaucoma services are considered RHC/FQHC services. For claims with dates of service before April 1, 2005, RHCs and FQHCs bill the FI under bill type 71X or 73X along with revenue code 0770 and HCPCS codes G0117 or G0118 and RHC/FQHC revenue code 0520 or 0521 to report the ...
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
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
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 25th, 2015
Table of Preventive and Screening Services (Rev. 3232, 01-05-15)
By Jared Staheli | Published June 25th, 2015
Service
CPT/HCPCS Code
Long Descriptor
USPSTF Rating
Coins./ Deductible
Initial Preventive Physical Examination, IPPE
G0402
Initial preventive physical examination; face to face visits, services limited to new beneficiary during the first 12 months of Medicare enrollment
*Not Rated
WAIVED
Initial Preventive Physical Examination, IPPE
G0403
Electrocardiogram, routine ECG with 12 leads; performed as a screening for the initial preventive physical examination with ...
June 25th, 2015
Healthcare Common Procedure Coding System (HCPCS) and Diagnosis Codes (Rev. 2824, 04-07-14)
By Jared Staheli | Published June 25th, 2015
Vaccines and their administration are reported using separate codes. The following codes are for reporting the vaccines only.
HCPCS
Definition
90653
Influenza virus vaccine, inactivated, subunit, adjuvanted, for intramuscular use
90654
Influenza virus vaccine, split virus, preservative-free, for intradermal use, for adults ages 18 – 64;
90655
Influenza virus vaccine, split virus, preservative free, for children 6- 35 ...
June 25th, 2015
CWF A/B Crossover Edits for FI/AB MAC and Carrier/AB MAC Claims (Rev. 2824, 04-07-14)
By Jared Staheli | Published June 25th, 2015
When CWF receives a claim from the carrier/AB MAC, it will review Part B outpatient claims history to verify that a duplicate claim has not already been posted.
CWF will edit on the beneficiary HIC number; the date of service; the influenza virus procedure codes 90653, 90654, 90655, 90656, 90657, 90660, ...
June 25th, 2015
HCPCS and Diagnosis Codes for Mammography Services (Rev. 3232, 01-05-15)
By Jared Staheli | Published June 25th, 2015
The following HCPCS codes are used to bill for mammography services.
HCPCS Code
Definition
77051*(76082*)
Computer aided detection (computer algorithm analysis of digital image data for lesion detection) with further physician review for interpretation, with or without digitization of film radiographic images, diagnostic mammography (list separately in addition to code for primary procedure). Code ...
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
Completion of Certificate of Medical Necessity Forms (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
1. SECTION A: (This may be completed by supplier.)
a. Certification Type/Date - If this is an initial certification for this patient, the date (MM/DD/YY) is indicated in the space marked "INITIAL". If this is a revised certification (to be completed when the physician changes the order, based on the patient's ...
June 18th, 2015
Completion of the Elements of PEN CMN (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
The patient's name, address, and HICN and the nature of the certification (i.e., initial, renewed, or revised) must be entered on all certifications by the supplier, physician, or physician's designated employees. The supplier identifying information is required on all PEN certifications.
All medical and prescription information must be completed from the ...
June 18th, 2015
Application of DMEPOS Fee Schedule (Rev. 1, 10-01-03)
By Jared Staheli | Published June 18th, 2015
Services that are paid under the DME fee schedule are identified in the DMEPOS fee schedule file available free on the CMS Web Site at: http://www.cms.hhs.gov/providers/pufdownload/default.asp
The DMEPOS fee schedule applies to claims to FIs as follows.
BILL TYPE/ DEFINITION
ORTHOTICS/ PROSTHETICS
DME/ OXYGEN
12X (Hospital inpatient Part B)
Subject to fee schedule
Not covered, therefore, ...
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 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
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
Institutional Provider Reporting of Service Units for DME and Supplies (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
Provider outpatient departments report service units using the ASC X12 837 institutional claim format or on the Form CMS 1450 the number of items being billed for orthotic and prosthetic devices.
For purchased DMEPOS items (excluding items requiring frequent and substantial servicing, capped rental items, and oxygen which cannot be purchased) ...
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 17th, 2015
Elimination of "Kit" Codes and Pricing of Replacement Codes (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
Prior to 2002, most suppliers billed for dialysis supplies using codes describing "kits" of supplies. The use of kit codes allowed suppliers to bill for supply items without separately identifying the supplies that are being furnished to the patient. Effective January 1, 2002, these kit codes were deleted and suppliers ...
June 17th, 2015
Daily Payment for Continuous Passive Motion (CPM) Devices (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
The CPM devices (HCPCS code E0935) are classified as items requiring frequent and substantial servicing and are covered as DME as follows (see the Medicare National Coverage Determinations Manual.):
• Continuous passive motion devices are covered for patients who have received a total knee replacement. To qualify for coverage, use of ...
June 17th, 2015
Payment of DMEPOS Items Based on Modifiers (Rev. 489, 07-05-05)
By Jared Staheli | Published June 17th, 2015
The following modifiers were added to the HCPCS to identify supplies and equipment that may be covered under more than one DMEPOS benefit category:
• AU Item furnished in conjunction with a urological, ostomy, or tracheostomy supply;
• AV Item furnished in conjunction with a prosthetic device, prosthetic or orthotic; and
• AW ...
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 ...
June 15th, 2015
Billing for Unlisted Drug Codes J3490 J9999 and C9399
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 15th, 2015 - Last Review/Update August 17th, 2017
When billing for unlisted drug codes J3490 and J9999 you must indicate the name, strength, and dosage of the drug in block 19 on the CMS-1500 claim form (or in 2400.SV101-7 in theANSI 837 claim file). It is extremely important to review the complete long descriptors in the HCPCS code, for the applicable HCPCS codes ...
June 15th, 2015
Billing for Unlisted Drug Codes J3490 J9999 and C9399
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 15th, 2015 - Last Review/Update August 8th, 2017
When billing for unlisted drug codes J3490 and J9999 you must indicate the name, strength, and dosage of the drug in block 19 on the CMS-1500 claim form (or in 2400.SV101-7 in theANSI 837 claim file). It is extremely important to review the complete long descriptors in the HCPCS code, for the applicable HCPCS codes you can ...
April 28th, 2015
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 28th, 2015 - Last Review/Update January 25th, 2017
FACT SHEET
April 24, 2015
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
OVERVIEW: On April 24, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule outlining proposed fiscal year (FY) 2016 Medicare payment policies and ...
April 24th, 2015
Have you been excluded from Medicare?
By Dr. Chris Andersn | Published April 24th, 2015 - Last Review/Update June 9th, 2016
Compliance is an issue that you should look at as an expedition rather than an endpoint. Board complaints can be a terrifying ordeal, especially if you don’t keep up on compliance in your clinic. Board complaints are something that you have to expect to happen but you can turn that ...
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 ...
April 15th, 2015
SGR Repeal Passes
By Wyn Staheli, Director of Research | Published April 15th, 2015 - Last Review/Update February 3rd, 2017
On April 14, 2015, the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA) passed the Senate by an overwhelming vote of 92-8. Although President Obama has not officially signed the bill into law, weeks ago he indicated his full support when H.R. 2 passed the House of Representatives.
For over a decade, ...
April 9th, 2015
G0105 - Colorectal Cancer Screening; Colonoscopy on Individual at High Risk
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 9th, 2015 - Last Review/Update August 8th, 2017
Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). ...
March 27th, 2015
Will the SGR be Repealed?
By Wyn Staheli, Director of Research | Published March 27th, 2015 - Last Review/Update June 9th, 2016
It appears that the repeal of the Sustainable Growth Rate formula (SGR) could finally be a real possibility. On Thursday, March 26, The U.S. House of Representatives overwhelmingly passed H.R 2, The Medicare Access and CHIP Reauthorization Act which includes both repeal and replace the flawed SGR formula that has ...
March 16th, 2015
Plantar Fasciitis: Medical Necessity and Cross Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 16th, 2015 - Last Review/Update August 9th, 2017
Prior to treatment you must determine Medical Necessity.
Be sure conservative therapy/treatment was previously done and documented for at least 6 months and proven to be unsuccessful.
NSAIDS - at least 4 weeks ineffective or contraindicated
Physical Therapy such as taping and stretching
Activity modification
Splints used at night for more that 4 weeks
Corticosteroid injection
Arch Supports, ...
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 ...
February 26th, 2015
Levels of Supervision Required by Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 26th, 2015 - Last Review/Update March 2nd, 2016
Be sure you know and understand the levels of supervision required so as not to result in non-compliance audits, possible fines and take-backs. Supervision requirements may also affect your documentation requirements; be sure to document the presence during the procedure or performance if it requires personal supervision.
Find-A-Code has levels of supervision ...
February 25th, 2015
Aetna Policy on Bathroom and Toilet Equipment and Supplies - Coverage
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 25th, 2015 - Last Review/Update February 18th, 2016
Clinical Policy Bulletin:Bathroom and Toilet Equipment and Supplies
Number: 0429
Policy Aetna's HMO-based and health network plans (HMO, QPOS, Health Network Only, Health Network Option, Golden Medicare, and U.S. Access) generally follow Medicare's criteria for durable medical equipment (DME) items that are used in the bathroom. Most DME items used in the bathroom are ...
February 21st, 2015
Implementation of a Prospective Payment System (PPS) for Federally Qualified Health Centers (FQHCs)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 21st, 2015 - Last Review/Update March 1st, 2016
CMS is establishing five specific payment codes to be used by FQHCs submitting claims under the PPS:
1. G0466 – FQHC visit, new patient A medically-necessary, face to face encounter (one-on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services are rendered and includes ...
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
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 13th, 2015
Chiropractic Services - Aetna Clinical Policy Bulletin
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 13th, 2015 - Last Review/Update March 1st, 2016
AETNA
Clinical Policy Bulletin: Chiropractic Services
Number: 0107
http://www.aetna.com/cpb/medical/data/100_199/0107.html
Policy
Note: Some plans have limitations or exclusions applicable to chiropractic care. Please check benefit plan descriptions for details.
Aetna considers chiropractic services medically necessary when all of the following criteria are met:
The member has a neuromusculoskeletal disorder; and
The medical necessity for treatment is clearly documented; and
Improvement is ...
February 10th, 2015
MAC Jurisdictions Resources
By | Published February 10th, 2015 - Last Review/Update February 18th, 2016
The Centers for Medicare & Medicaid Services (CMS) uses a network of contractors called Medicare Administrative Contractors (MAC) to process Medicare claims, enroll health care providers in the Medicare program and educate providers on Medicare billing requirements. MACs also handle claims appeals and answer beneficiary and provider inquiries. Even though ...
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 5th, 2015
Medicare Resources
By | Published February 5th, 2015 - Last Review/Update April 5th, 2018
For detailed information on this government program, as it relates to Chiropractic services, see Section C-Medicare in theChiroCode DeskBook.
You need to understand the following concepts:
Enrollment/Revalidation
How Medicare Payment Works
Medicare as Secondary Payer (MSP) - resource 218 and 219
MAC Jurisdictions
Medicare Coverage of Chiropractic Services
Maintenance Care vs Active Care - resource
Medicare Appeals
Physician Quality Reporting System (PQRS) - resource 317
Advance ...
February 3rd, 2015
PPACA Provider Non-Discrimination FAQ
By | Published February 3rd, 2015 - Last Review/Update June 9th, 2016
The following information (emphasis added) is from: http://www.cms.gov/CCIIO/Resources/Fact-Sheets-and-FAQs/aca_implementation_faqs15.html
Provider Non-Discrimination PHS Act section 2706(a), as added by the Affordable Care Act, states that a “group health plan and a health insurance issuer offering group or individual health insurance coverage shall not discriminate with respect to participation under the plan or coverage against ...
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 ...
December 23rd, 2014
CMS Announces New HCPCS Modifiers to be Implemented January 2015
By | Published December 23rd, 2014 - Last Review/Update January 30th, 2017
Beginning January 5, 2015 CMS (Centers for Medicare and Medicaid Services) requires new HCPCS modifiers to be used in place of modifier 59 for all Medicare claims.
These new subset modifiers are known as -X{ESPU} and are defined as follows:• XE - separate encounter, a service that is distinct because it ...
December 19th, 2014
Medicare Parts C & D Fraud, Waste, and Abuse Training and General Compliance Training
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 19th, 2014 - Last Review/Update March 1st, 2016
All persons who provide health or administrative services to Medicare enrollees must satisfy general compliance and FWA training requirements. This module may be used to satisfy both requirements.
This training module consists of two parts:
(1) Medicare Parts C & D Fraud, Waste, and Abuse (FWA) Training and Compliance
Objectives:
Meet the regulatory requirement ...
December 19th, 2014
Compliance Program - What are the Requirements to Implement an Effective Program
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 19th, 2014 - Last Review/Update March 1st, 2016
All sponsors are required to adopt and implement an effective compliance program,which must include measures to prevent, detect and correct Part C or D program noncompliance as well as FWA.
The compliance program must, at a minimum, include the following core requirements:
1. Written Policies, Procedures and Standards of Conduct;
2. Compliance ...
December 18th, 2014
Coding for ICD-10-CM: More of the Basics MLN Connectsâ„¢ Video
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 18th, 2014 - Last Review/Update March 1st, 2016
In this MLN Connects™ video on Coding for ICD-10-CM: More of the Basics, Sue Bowman from the American Health Information Management Association (AHIMA) and Nelly Leon-Chisen from the American Hospital Association (AHA) provide a basic introduction to ICD-10-CM coding. The objective of this video is to enhance viewers’ understanding of ...
December 4th, 2014
NCDs and LCDs - What Are They?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
What are NCDs and LCDs?
NCD — NATIONAL COVERAGE DETERMINATIONS
Medicare specific coverage on the national level. All Medicare carriers are required to follow the NCDs. The NCDs are developed by CMS to describe the circumstances for Medicare coverage nationwide for an item or service. NCDs generally outline the conditions for which an ...
December 4th, 2014
New G-Codes Released by CMS for FQHC PPS (Federally Qualified Health Centers)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Medicare has established 5 new codes for reporting FQHC (Federally Qualified Health Center) services effective Oct 01, 2014. Very specific guidelines are to be followed for proper reimbursement.
G0466 — A medically-necessary, face to face encounter (one-on-one) between a new patient and a FQHC practitioner during which time one or more FQHC services ...
December 4th, 2014
OASIS Data to be Submitted via Assessment Submission and Processing (ASAP) System Effective Jan 1, 2015
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Effective January 1, 2015, OASIS assessment data will be submitted to CMS via the national OASIS Assessment Submission and Processing (ASAP) system. With the implementation of the OASIS ASAP system, Home Health Agencies will no longer submit OASIS assessment data to CMS via their state databases. To access the ...
December 4th, 2014
CMS - Final Rule to Deny or Revoke the Enrollment of Entities that Pose an Integrity Risk to Medicare
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
On December 3, 2014, the Centers for Medicare & Medicaid Services (CMS) issued a final rule that will improve CMS’ ability to deny or revoke the enrollment of entities and individuals that pose a program integrity risk to Medicare.
This fact sheet summarizes CMS’ regulatory additions and changes.
SUMMARY OF THE PROVIDER ...
December 4th, 2014
Durable Medical Equipment - Documenting Continued Use
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Treating physicians’ records often omit documentation of a beneficiary’s continuing use of durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). By Medicare statute, lack of physician documentation regarding a beneficiary’s continued need and use of an item of DMEPOS will result in claim denials. Many “model charts” from various clinical ...
December 4th, 2014
Vacuum Erection Devices (VED)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Vacuum pumps coded L7900 must demonstrate a capability to generate a negative pressure in the range of greater than 3.9 and less than 17 inches of mercury (100 and 432 mmHg, respectively). All devices coded L7900 for reimbursement by Medicare must include a vacuum limiter such that a maximum vacuum ...
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 4th, 2014
Correct Coding MyoPro® (Myomo, Inc.) Assist Device
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
The Durable Medical Equipment Medicare Administrative Contractors (DME MACs) have evaluated the MyoPro® upper extremity assist device and determined that it falls within the Durable Medical Equipment (DME) benefit category. Claims for MyoPro® should be submitted using the DME miscellaneous code E1399.
Suppliers are reminded that when submitting claims for items ...
December 4th, 2014
Correct Coding and Coverage of Ventilators
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
Joint DME MAC Publication
Ventilator technology has evolved to the point where it is possible to have a single device capable of operating in numerous modes, from basic continuous positive pressure (CPAP and bi-level PAP) to traditional pressure and volume ventilator modes. This creates the possibility that one piece of equipment ...
December 4th, 2014
Correct Coding: Lithium Batteries
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
The DME MACs have recently noted confusion on the part of DMEPOS suppliers regarding the proper billing of lithium batteries. There are two types of lithium batteries Lithium batteries and Lithium Ion batteries. Lithium ion batteries are commonly used in consumer electronic devices and are rechargeable. Standard lithium batteries are disposable, non-rechargeable batteries. ...
December 4th, 2014
Coverage and Correct Coding of Continuous Glucose Monitoring Devices
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
Joint DME MAC Publication
Continuous glucose monitoring (CGM) devices measure glucose in the interstitial fluid, not capillary blood, providing interstitial glucose readings every few minutes. CGM systems are composed of several components — disposable sensors that are inserted in the subcutaneous tissue, a transmitter that relays information to the receiver, and a ...
December 4th, 2014
Off the Shelf - OTS Orthotics New Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
In February 2012, The Center for Medicare and Medicaid Services (CMS) issued guidance that initially identified specific Healthcare Common Procedure Coding System (HCPCS) codes that were considered Off-the-Shelf (OTS) orthoses. The list of HCPCS codes that were finalized as part of this review as OTS orthotics, effective January 1, 2014, ...
December 4th, 2014
Correct Coding - Cefaly®
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
The Cefaly® device (Cefaly Technology) is a transcutaneous electrical nerve stimulator (TENS) that is applied to the forehead using a self-adhesive electrode positioned bilaterally over the upper branches of the trigeminal nerve. The Cefaly® device is intended to stimulate the upper branches of the trigeminal nerve and has received Food ...
December 4th, 2014
Correct Coding: Braces (Orthoses) Attached to Wheelchairs
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update August 9th, 2017
Joint DME MAC and PDAC Publication
Recently, claims for braces attached to wheelchairs have been submitted using HCPCS code K0108 - WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED. K0108 is not the correct HCPCS code to use for these items.
CMS has clarified the distinction between braces (orthoses) and durable medical equipment (DME) under Medicare Part ...
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 of Outcome Measures
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
The outcome of care measures and the utilization measures are risk adjusted. The process of care measures aren't risk adjusted. Risk adjustment of the outcome of care and utilization measures is a multi-step process. These are the major steps in this process displayed in temporal order:
OASIS-C assessment data collection and ...
November 21st, 2014
Aligning the Way Providers are Paid to Reward Value Rather than Volume (Value Based Modifiers)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
CMS is aligning the way providers are paid to reward value rather than volume.
Paying providers for quality, not quantity of care. In 2015, Medicare is continuing to phase in the Value-based Payment Modifier, which adjusts traditional Medicare payments to physicians and other eligible professionals based on the quality and ...
November 21st, 2014
CMS Will Begin Applying the Value Modifier in Calendar Year (CY) 2017 to All Physicians
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
CMS will begin applying the Value Modifier in calendar year (CY) 2017 to all physicians; including those in groups with two or more eligible professionals (EPs), and to physicians who are solo practitioners. This policy completes the phase-in of the Value Modifier to all physicians and groups of physicians as ...
November 21st, 2014
CMS Announces a Getting Started with Quality Measures Virtual Office Hours Session for 2014 Physician Quality Reporting System (PQRS)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 21st, 2014 - Last Review/Update March 1st, 2016
The Centers for Medicare & Medicaid Services (CMS) is pleased to announce that a Virtual Office Hours session regarding Getting Started with Quality Measures has been scheduled for Monday, November 17, 2014 from 3:00–4:00 PM ET
This session will allow stakeholders an opportunity to ask a CMS representative questions about getting ...
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
Coding for Laser Therapy
By | Published November 21st, 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 diagnoses code.
Coverage for laser, as with any other service, is strictly dependent upon the ...
November 19th, 2014
Understanding ZPIC
By | Published November 19th, 2014 - Last Review/Update January 30th, 2017
The following chart identifies each of the 7 zones for ZPIC and the states/regions within each zone. Links are provided for each zone which contain information about each zone as well as activity and updates in those regions.
November 19th, 2014
Understanding RAC
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published November 19th, 2014 - Last Review/Update January 30th, 2017
Recovery Audit Contractors, also known as RAC, is a program that seeks to identify and correct improper payments for services provided to Medicare Parts A & B beneficiaries. This includes both recoupment of overpayments and corrected distribution of underpayments made by CMS.  RAC began in 2005 as a three-year demonstration project consisting ...
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 20th, 2014
CMS Announces 2013 eRx Incentive Program Payments are Now Available
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 20th, 2014 - Last Review/Update March 2nd, 2016
CMS is pleased to announce that the 2013 Electronic Prescribing (eRx) Incentive Program incentive payments are now available for eligible professionals and group practices who submitted data for Medicare Physician Fee Schedule Part B services provided January 1, 2013 through December 31, 2013.
As required by law, President Obama issued a ...
October 17th, 2014
Medicare Billing Information for Rural Providers and Suppliers Booklet - Revised
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 17th, 2014 - Last Review/Update January 30th, 2017
The “Medicare Billing Information for Rural Providers and Suppliers” Booklet (ICN 006762) was revised and is now available in downloadable format. To assist rural providers who have limited internet access, see the “Medicare Billing Information for Rural Providers and Suppliers Text-Only”
Booklet is available in text-only format. This booklet is designed ...
October 17th, 2014
Billing Requirements for Medicare Secondary Payer (MSP) Provisions
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 17th, 2014 - Last Review/Update January 30th, 2017
MSP provisions apply to situations when Medicare is not the beneficiary’s primary health insurance coverage. Before you submit a claim, you must determine whether Medicare is the primary or secondary payer for all inpatient admissions and outpatient encounters, thereby assisting in ensuring the appropriate use of Medicare funds. If another ...
October 16th, 2014
Is Compliance a Dirty Word?
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 16th, 2014 - Last Review/Update January 23rd, 2017
In October of 2000 in the Federal Register the Office of the Inspector General (who investigates fraud against the federal government on behalf of the Department of Health and Human Services) offered general guidelines for health care facilities to set up a “Compliance Program”. This advice has long been pushed ...
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
Chiropractic is Listed as a Priority in the 2014 OIG Work Plan...Find Out Why
By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published October 16th, 2014 - Last Review/Update January 30th, 2017
Each year the Office of Inspector General (OIG) issues an updated work plan which outlines the objectives and enforcement priorities for each new year. For Medical providers, including Chiropractic, this information is necessary to review and be familiar with so we may evaluate our own practice systems to ensure compliance ...
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
ABN FAQ for Chiropractic Care
By | Published October 16th, 2014 - Last Review/Update November 29th, 2017
What is the ABN form used for?
The Advanced Beneficiary Notice of Non-Coverage (ABN) is the Notice of Liability that is required to be provided to Medicare patients in the event that the service(s) rendered to them are expected to not be covered. For chiropractic, reason for non-coverage is generally due ...
October 9th, 2014
Medicare Caps on Therapy Services
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 9th, 2014 - Last Review/Update January 23rd, 2017
Medicare has set annual therapy caps at $1920 and they start over Jan. 1 of each year. Medicare combined the therapy limits SLP (Speech-Language Pathology) and PT (Physical Therapy) for a combined total of $1920.00 in 2014. There is also a therapy cap limit for OT (Occupational Therapy) Services of $1920. ...
October 9th, 2014
Effective Billing Dates for New CMS Providers
By | Published October 9th, 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 ...
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 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 26th, 2014
Patient Electronic Access Tipsheet - Measure Compliance
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 26th, 2014 - Last Review/Update January 30th, 2017
MEASURE COMPLIANCE - Meeting the Patient Electronic Access Objective
Starting in 2014, CMS requires that providers participating in both Stage 1 and Stage 2 of the EHR Incentive Programs must meet the Patient Electronic Access objective, which gives patients access to their health information in a timely manner. Providers participating in ...
September 25th, 2014
PQRS: Questions and Answers for Psychologists
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
Questions and Answers for Psychologists and PQRS. In 2007, Psychologists had very limited opportunity to participate in PQRS. As of 2014, there are 11 measures available for claims-based reporting and two for registry reporting.
For the entire article read more here: PracticeCentral.org
Below are the 11 new measures for 2014
Major depressive disorder: diagnostic evaluation (#106)
Major ...
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 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 9th, 2014
Face-to-Face Encounter Compliance Requirement for Certain Durable Medical Equipment
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 9th, 2014 - Last Review/Update January 30th, 2017
On September 9, 2013, the Centers for Medicare & Medicaid Services (CMS) announced that it would begin actively enforcing and would expect full compliance with new DME face-to-face requirements on a date to be announced in Calendar Year 2014. We are publishing this announcement to make clear that the delay ...
August 27th, 2014
PQRS FAQS
By | Published August 27th, 2014 - Last Review/Update January 30th, 2017
PQRS FAQs: How do I report for the 2014 PQRS? What is the MAV and when does it apply? What happens if we report less than 9 measures across 3 domains? How does CMS apply the MAV Clinical Relation/Domain test for PQRS?
August 26th, 2014
Q & A: Does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 26th, 2014 - Last Review/Update August 9th, 2017
Q: When meeting the meaningful use measure for computerized provider order entry (CPOE) in the Electronic Health Records (EHR) Incentive Programs, does an individual need to have the job title of medical assistant in order to use the CPOE function of Certified EHR Technology (CEHRT) for the entry to count toward ...
August 12th, 2014
CMS-gov E-Health information
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 12th, 2014 - Last Review/Update January 23rd, 2017
Information related to Medicare's E-Health programs can be viewed here. (Click Here) E-Health includes: E-Prescribing Electronic Health Records Personal Health Records EHR Incentive Programs  eRx Electronic Prescribing Incentive Program (Click Here) The eRx Incentive Program Ended in 2013, but Electronic Prescribing Continues with Meaningful Use. ...
August 12th, 2014
How do I find a HCPCS code for a laxative given to a patient in our office?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 12th, 2014 - Last Review/Update August 9th, 2017
A Laxative is considered a “Self Administered Drug” (SAD). Insurance will usually pay for the care you provide but will only cover certain drugs in the outpatient setting such as drugs administered through an IV. Therefore it would not be appropriate to report this under the Outpatient Prospective Payment System ...
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 ...
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
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 24th, 2014
Are Medicare fees going up? Or down?
By | Published July 24th, 2014 - Last Review/Update January 29th, 2016
Are Medicare fees going up? Or down? Results for the following:
Sequestration
Chiropractic Demonstration Project
Electronic Health Record/Meaningful Use
Physician Quality Reporting System - PQRS
Value-Based Modifier
July 16th, 2014
Coding Screening Mammograms
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 16th, 2014 - Last Review/Update January 25th, 2017
Mammography is a method of taking x-ray images of the breasts to identify tumors or abnormalities in the tissues that may indicate breast cancer. Screening Mammography: Screenings are performed on otherwise healthy individuals to look for cancer or precursors to cancer of the breasts. Early detection of breast cancer ...
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 ...
April 17th, 2014
EFT Standardization Looks Promising
By | Published April 17th, 2014 - Last Review/Update January 25th, 2017
January 1, 2014 was the required date for adoption of standards for both Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). The Centers for Medicare & Medicaid Services (CMS) recently announced that the implementation of these new standards has resulted in benefits for both providers and CMS. Not surprisingly, ...
January 1st, 2014
Testing & Screening Tools
By Wyn Staheli, Director of Research | Published January 1st, 2014 - Last Review/Update October 4th, 2017
There are numerous types of behavioral health screening tools for healthcare providers. Some, like the AUDIT and SBIRT are especially applicable to primary care providers caring for Medicare beneficiaries.
This page includes some general information and resources for some of these screening tools. Let us know if you would like others included ...
November 8th, 2013
Modifiers –Reimbursement or Informational?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 8th, 2013 - Last Review/Update November 3rd, 2017
Modifiers are used to help describe the encounter, and used to further explain the procedure to the payer. Modifiers will be used if the procedure does not fit or clearly explain the entire encounter.
There are two types of modifiers:
Informational modifiers that do not impact reimbursement
Pricing or Payment modifiers that ...
August 30th, 2012
Inappropriate Medicare Payments for Chiropractic Services
By | Published August 30th, 2012 - Last Review/Update January 27th, 2017
OIG released two reports critical of the way chiropractic handled documentation and coding. Their findings are included in this article. Read further to see what documentation is needed for proper payment.
As required by the Social Security Act, Medicare pays only for reasonable and necessary chiropractic services, which are limited to active/corrective manual manipulations of the spine to correct subluxations. A chiropractic service must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.
December 31st, 2001
Commonly Asked Chiropractic Coding Questions
By ChiroCode | Published December 31st, 2001 - Last Review/Update August 19th, 2015
Commonly Asked Questions:
1. Retention of Records
2. 97140 Denials
3. Exercise Equipment
4. Coding for BioFreeze
5. 97014 or G0283
6. Billing for additional insurance forms
7. Report of Findings
8. Laser therapy
9. Spinal Decompression
10. Diagnosis Coding – 4th and 5th digit
11. Re-Reading X-rays
12. Outcomes Assessment Questionnaires
13. Accounts Receivable
14. 15-Minute Units
15. E/M and CMT
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