"Payer: CMS|Medicare" & "Modifier Coding" Articles
Click on the title to see the article summary and a link to the full article.
February 11th, 2021
2021 Medicare Physician Fee Schedule Updates - Do You Really Need to Worry?
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.
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 8th, 2020
Significant COVID-19 Code Changes as of October 6
By Wyn Staheli, Director of Research | Published October 8th, 2020 - Last Review/Update October 13th, 2020
Significant COVID-19 Code Changes as of October 6
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.
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 ...
August 10th, 2020
Modifier 50 — Four "Must Know" Tips For Getting Paid
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published August 10th, 2020
Modifiers added to an HCPCS or CPT© code alters the code description, providing clarity about the service for proper claim processing and reimbursement. Here are four things you must know about modifier 50 to ensure proper payment. - Modifiers are either informational or payment related. Informational modifiers provide additional...
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 14th, 2020
Are NCCI Edits and Modifiers Just for Medicare?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 14th, 2020
The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that ...
July 9th, 2020
Payment Adjustment Rules for Multiple Procedures and CCI Edits
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2020
Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...
June 10th, 2020
MEGA - NCCI Edit Changes - WHO Knew?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 10th, 2020
There was no huge announcement when CMS released new files in April. The files that were released on April 7, 2020, actually replaced files to update the NCCI edits on Procedure to Procedure (PTP) edits and Medically Unlikely Edits (MUE). The updated files included;
291,902 Deleted Procedure to Procedure (PTP) edits
197 Deleted Medically Unlikely ...
May 20th, 2020
Where is the CCI Edit with Modifier 25 on E/M?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 20th, 2020
If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.
The use of Modifier 25 is one example ...
May 13th, 2020
Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 13th, 2020
On April 10th, CMS released a memo with the subject line, “Applicability of diagnoses from telehealth services for risk adjustment,” suggesting there may be some telehealth services that might not qualify for risk adjustment. However, in the memo CMS states:
“Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face ...
May 4th, 2020
Additional Telehealth Changes Announced by CMS
By Wyn Staheli, Director of Research | Published May 4th, 2020
On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.
April 20th, 2020
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 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 7th, 2020
More Telehealth Changes Announced by CMS Chiropractic Offices Should Know About
By Wyn Staheli, Director of Research | Published April 7th, 2020
On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). The announcement included far more information than is presented in this article which only summarizes the changes to telehealth. In fact, it does change a little of the information included in our March 31st webinar.
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 31st, 2020
CMS-Coverage for Therapeutic Shoes for Individuals with Diabetes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 31st, 2020
Therapeutic shoes and inserts can play a vital role in a diabetic patient's health. Medicare may cover one pair every year and three pairs of custom inserts each calendar year if the patient qualifies and everything is handled correctly. Medicare Benefit Policy Manual explains what is needed for a person with diabetes to ...
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 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 ...
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 14th, 2020
Billing for Telemedicine in Chiropractic
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published January 14th, 2020
Many large private payers recognize the potential cost savings and improved health outcomes that telemedicine can help achieve, therefore they are often willing to cover it. While there are several considerations, there could be certain circumstances where telemedicine might apply to chiropractic care.
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 19th, 2019
Q/A: How do I Code a Procedure for the Primary Insurance so the Secondary Can Get Billed?
By Wyn Staheli, Director of Research | Published November 19th, 2019
Question: How do you modify a code submitted to the primary insurance company to let them know it is not covered by them so you can bill to a secondary?
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 18th, 2019
Medically Unlikely Edits (MUEs): Unlikely, But Not Always Impossible
By Namas | Published October 18th, 2019 - Last Review/Update October 23rd, 2019
Medically Unlikely Edits (MUEs) were created by the Centers for Medicare & Medicaid Services (CMS) to help lower the error rate for paid Part B claims. MUEs are the maximum units of a HCPCS or CPT code that a provider would bill under most circumstances for the same patient on ...
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 ...
September 30th, 2019
Q/A: How Do I Bill a House Call?
By Wyn Staheli, Director of Research | Published September 30th, 2019
Question
If a provider makes a house call to/for a patient, is there a way that it is represented on the claim form? A modifier, or something else?
Answer
Modifiers are not used to identify that a service was performed in the patient's home. However, other modifier rules must be followed (e.g., modifier GP ...
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 19th, 2019
Understanding Payment Indicators
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 19th, 2019
Understanding how payment works with Medicare payment indicators and the impact a modifier has on payment is vital to pricing. Even if you are not billing Medicare, most carriers follow Medicare's policies for participating and non-participating rules. Here is an article from Regence on their policy statement, describing the rules ...
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 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
Q/A: Do I Use 7th Character A for all Sprain/Strain Care Until MMI?
By Wyn Staheli, Director of Research | Published July 15th, 2019
Question:
It is in regards to the Initial and Subsequent 7th digit (A and D) for sprains and strains. Recently, I have been told that I should continue with the A digit until the patient has reached Maximum Medical Improvement (MMI) and then switch over to the D place holder. Is ...
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 ...
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
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 27th, 2019
Q/A: For Physical Therapy Claims, What is the Correct Modifier Order?
By Wyn Staheli, Director of Research | Published May 27th, 2019 - Last Review/Update June 6th, 2019
Question
Page 116 of the 2019 ChiroCode Deskbook shows examples for Medicare modifiers. Is this the specific order for the modifiers to be entered? Our practice management software system is advising the GP or GY should be used as Modifier 1 and not as Mod 2 or Mod 3.
Also, it shows the ...
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 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
Q/A: I Submitted a Claim to the VA and it’s Being Denied. Why?
By Wyn Staheli, Director of Research | Published April 1st, 2019
I submitted a claim to the VA and it’s being denied. Why?
There are several reasons why your claim might be denied by the Veterans Administration (VA). However, without more information about the claim itself (e.g., services billed), we can only provide the following general information about the VA and chiropractic ...
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
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 26th, 2019
CPT Codes Exempt from Modifier 51 (Appendix E)
By Find-A-Code | Published March 26th, 2019 - Last Review/Update April 2nd, 2019
The following CPT codes are exempt from the use of modifier 51. These procedures are usually performed with another procedure, however, they may also be a stand-alone procedure.
17004
93456
93618
20697
93503
93631
20974
93600
94610
20975
93602
95905
31500
93603
95992
36620
93610
99151
44500
93612
99152
61007
93615
93451
93616
...
March 26th, 2019
CPT Codes That Should Not Be Reported With Modifier 63 (Appendix F)
By Find-A-Code | Published March 26th, 2019 - Last Review/Update April 2nd, 2019
The following codes should not be reported with modifier 63.
30540
33946
46735
30545
33947
46740
31520
33978
46742
33470
33949
46744
33502
36415
47700
33503
36420
47701
33505
36450
49215
33506
36456
49491
33610
36460
49492
33611
36510
49495
33619
36660
46196
33647
39503
49600
33670
43313
49605
33690
43314
49606
33694
43520
49610
33730
43831
19611
33732
44055
53025
33735
44126
54000
33736
44127
54150
33750
44128
54160
33755
46070
63700
33762
46705
63702
33778
46715
63704
33786
46716
63706
33922
46730
65820
...
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 18th, 2019
How to Report Imaging (X-Rays) of the Thumb
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 18th, 2019
If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all ...
March 7th, 2019
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 1st, 2019
Understanding NCCI Edits
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 1st, 2019
Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...
February 22nd, 2019
Q/A: What's the Difference Between Q5 and Q6 for a Substitute Provider?
By Wyn Staheli, Director of Research | Published February 22nd, 2019 - Last Review/Update March 5th, 2019
It is important to understand that modifiers Q5 and Q6 are not interchangeable. So when do you use each of them?
February 22nd, 2019
Separately Report a "Separate Procedure" with Confidence
By Namas | Published February 22nd, 2019 - Last Review/Update February 28th, 2019
Many procedures in the CPT® code book are designated "separate procedures," but that doesn't mean you can report those procedures separately in every case. First, you must consider other procedures performed during the same encounter.
"Separate" Might Not Mean What You Think It Does
You can always identify a designated separate procedure by the inclusion of "(separate ...
February 13th, 2019
Detection by Nucleic Acid (DNA or RNA) - Amplified Probe Technique
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 13th, 2019
This question was asked on the following lab codes used for testing during pregnancy. "Can the codes below be billed together? 87491- 59, 87591-59. 87081, 87150."
YES- CPT code 87081 is used when a specific pathogen is suspected and is appropriate.
YES- (X2) 87150 is used for culture, typing, and identification by nucleic ...
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
Q/A: Do Digital X-rays Have Their Own Codes?
By Wyn Staheli, Director of Research | Published February 7th, 2019 - Last Review/Update February 8th, 2019
Question
Are you aware if digital x-ray of the spine requires a different code than plain x-ray? If so, where can I find the information specific to digital x-ray codes?
Answer
There are no separate codes for digital x-rays. However, there may be modifiers that are required to be submitted with the usual ...
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
Q/A: Can I Bill a Review of X-Rays?
By Wyn Staheli, Director of Research & Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT | Published February 1st, 2019
It is not unusual for a healthcare provider to review x-rays taken and professionally read by another entity. Questions arise regarding how to bill this second review. It is essential to keep in mind that the global (complete) service of taking an x-ray is composed of both a professional and ...
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
How to Report Co-Surgeons Using Modifier 62
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2019
Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session.
An easy way to explain this is to visualize a patient requiring cervical fusion where ...
January 22nd, 2019
Home Oxygen Therapy
January 22nd, 2019
CPT Modifiers 96 & 97 for Habilitative and Rehabilitative Services (2018-01-01)
By Find-A-Code | Published January 22nd, 2019
Effective January 1, 2018, CPT modifiers 96 "habilitative services" and 97 "rehabilitative services" will be in effect. There have been questions on whether modifier 96 will be preferred over HCPCS modifier SZ, which describes the same types of habilitative (but not rehabilitative) services, but payers have not yet indicated which modifier ...
January 14th, 2019
AMA Issues new CMT Information
By Wyn Staheli, Director of Research | Published January 14th, 2019
As many of you may already be keenly aware, there have been ongoing problems with many payers (e.g., BCBS of Ohio) regarding the appropriateness of reporting an E/M visit on the same day as CMT (CLICK HERE to read article). The AMA recently released an FAQ which renders their opinion ...
January 4th, 2019
Nine New Codes for Fine Needle Aspirations (FNA) in 2019
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 4th, 2019
If your practice performs a lot of fine needle aspirations (FNA), you probably have the code options memorized (10021 without image guidance and 10022 with image guidance). However, the 2019 CPT codes now include nine (9) new FNA codes (10004-10012), one deleted FNA code (10022) and one revised FNA code ...
January 3rd, 2019
Dry Needling
By Wyn Staheli, Director of Research | Published January 3rd, 2019
The correct coding of dry needling, also known as trigger point needling, has been a subject of confusion for quite some time. The American Chiropractic Association (ACA) and the American Physical Therapy Association (APTA) have been working together for several years to obtain appropriate codes to describe this service. In ...
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 ...
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 ...
December 18th, 2018
Reporting Unilateral or Bilateral Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 18th, 2018 - Last Review/Update December 20th, 2018
Generally, Audiology tests are coded as if they were performed on both ears, if the testing was performed only on one ear, you are required to append a modifier to acknowledge there was a reduced service or a unilateral assessment, using modifier 52 - Reduced Services. (Be sure to read...
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 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 26th, 2018
Reciprocal Billing and Locum Tenens Arrangements Changes
By Wyn Staheli, Director of Research | Published November 26th, 2018
CMS has made changes to their payment policies for reciprocal billing arrangements and Fee-For-Time compensation arrangements (formerly referred to as locum tenens arrangements). Providers need to be aware of these changes and update their policies as appropriate.
November 9th, 2018
Billing 99211 Its not a freebie
By | Published November 9th, 2018 - Last Review/Update November 29th, 2018
It seems like a simple code to bill, but CPT 99211 (established patient office visit) is by no means a freebie when it comes to documentation and compliance. This lowest level office visit code is sometimes called a "nurse visit" because CPT does not require that a physician be present...
November 8th, 2018
Muscle Testing and Range of Motion Information
By Wyn Staheli, Director of Research | Published November 8th, 2018
Be sure to understand the unique code requirements for Muscle and Range of Motion Testing.
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 26th, 2018
Capped Rental Items
By | Published October 26th, 2018 - Last Review/Update January 9th, 2019
CMS Gives guidance on Capped Rental Items:
Items in this category are paid on a monthly rental basis not to exceed a period of continuous use of 13 months.
Based on Supplier Standard 5, suppliers are required to advise beneficiaries of the rent/purchase option for capped rentals and inexpensive or routinely purchased items. ...
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 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 ...
October 2nd, 2018
Use My Code Set to Save Priced Procedures
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 2nd, 2018
Use My Code Set to save priced procedures to refer to commonly used procedures. Once your CCI edits are done and you have your list of Codes, add notes to My Codes. Add all important information to the Code, for viewing again instead of re-working your most commonly used procedures....
October 1st, 2018
When to Use Modifier 25 and Modifier 57 on Physician Claims
By BC Advantage | Published October 1st, 2018 - Last Review/Update October 17th, 2018
The biggest thing modifiers 25 and 57 have in common is that they both assert that the E/M service should be payable based on documentation within the record showing the procedure should not be bundled into the E/M. After that, the similarities end, and it is important to know the...
September 28th, 2018
Chiropractic OIG Audit Recommendations - Lessons Learned
By Wyn Staheli, Director of Research | Published September 28th, 2018
The OIG recently concluded an audit on a chiropractic office located in Florida and had some significant findings. They recommended the following:
Refund to the Federal Government the portion of the estimated $169,737 overpayment for claims for chiropractic services that did not comply with Medicare requirements and are within the 4-year ...
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
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 ...
August 13th, 2018
Using Modifiers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 13th, 2018
Modifiers offer supplemental information and provide additional details without changing the procedure codes definition and are always two digits. Modifiers are required for proper billing and at times used with NCCI edits, however, two or more NCCI -associated modifiers on the same line will be denied. In addition, NCCI modifiers ...
July 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 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
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 7th, 2018
The Range of Motion Conundrum
By Gregg Friedman, DC, CCSP | Published June 7th, 2018 - Last Review/Update January 30th, 2019
As both a chiropractor for 31 years and one who reviews a lot of medical records for the medicolegal arena and has been teaching documentation for many years, the range of motion question comes up frequently. Although we used to get reimbursed very well for a specific range of motion code back in ...
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
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 22nd, 2018
AMA vs Medicare rules and the use of the PT modifier
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 22nd, 2018
Be sure to review the specific payer policy you are submitting claims to. 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. The use of the PT modifier is ...
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: 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: Human Papilomavirus (HPV) Vaccine and Screening
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Human Papilomavirus (HPV) Vaccine and Screening
Procedure Codes 87623: Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), low-risk types (eg, 6, 11, 42, 43, 44) 87624: Infectious agent detection by nucleic acid (DNA or RNA); Human Papillomavirus (HPV), high-risk types (eg, 16, 18, ...
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: Use of Modifier 33
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
The Use of Modifier 33
Modifier 33 is used to indicate Preventive Services to report quality metrics and is informational only, it has no impact on reimbursement. Modifier 33 should be reported only to private payers, Medicare and Medicaid do not recognize this modifier.
...
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 30th, 2018
Q/A: Should I be Using Modifier 96 on PT Claims?
By Wyn Staheli, Director of Research | Published April 30th, 2018 - Last Review/Update January 30th, 2019
As chiropractors we feel the new modifier 97 is more appropriate than 96 for our PT codes such as stim and traction. Yet Carefirst is asking for 96 only. Should we use this code on all the PT codes and for all the other insurance companies?
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 17th, 2018
Q/A: Modifiers for Injections
By Nicole Olsen QCC | Published April 17th, 2018 - Last Review/Update July 9th, 2018
I'm currently receiving a rejection for my billing with BCBS. We've entered 20550 and 20600 as services for the visit....
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
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 26th, 2018
Q/A: Which Modifiers to Use When Billing 44005 and 36556 Together
By Chris Woolstenhulme QCC, CMCS, CPC, CMRS | Published March 26th, 2018 - Last Review/Update April 11th, 2018
I have a denial for 44005 and 36556 being billed together. I added modifiers 51, 59, and Q6 to 36556 but I am afraid it will deny again?
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 13th, 2018
CPT Code for DOT exams
By Wyn Staheli, Director of Research | Published March 13th, 2018 - Last Review/Update January 31st, 2019
Question: I have a provider that provides Department of Transportation (DOT) exams. I have found ICD-10 code Z02.4 (encounter for examination for drivers license) but I am unsure which CPT Code to use. Would I still use 99203 or 99204?
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 5th, 2018
Increased Therapy Denials Create Administrative Burden
By Wyn Staheli, Director of Research | Published March 5th, 2018
Recently, many healthcare providers have begun to experience a downpour of denials when billing therapy services. The states which seem to be experiencing the most difficulty are Illinois, Oklahoma and Texas, particularly for claims submitted to BCBS plans owned by Health Care Service Corporation (HCSC). Since HCSC also owns Blues ...
March 1st, 2018
Anthem Will Not Give Modifier 25 a Pay Cut
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 1st, 2018
Anthems original plan was to take a 50% reduction when providers reported claims using modifier 25, it was then lowered to a 25% reduction and has now been fully rescinded, to the relief of providers. The policy was to go into effect March 1, 2018, however, due to strong opposition from ...
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 27th, 2018
CPT Modifers 96 & 97 for Habilitative and Rehabilitative Services
By Jared Staheli | Published February 27th, 2018
Effective January 1, 2018, CPT modifiers 96 "habilitative services" and 97 "rehabilitative services" will be in effect. CMS has added modifiers 96 and 97 to their edits (see MLN Matters MM10385 here) and modifier SZ is deleted as of December 31, 2017. Private payers should simply adjust their policies to use ...
February 26th, 2018
OIG Issues Renewed Focus on Chiropractic Services
By Wyn Staheli, Director of Research | Published February 26th, 2018
The OIG recently released a "Portfolio" regarding chiropractic service which stated (emphasis added):
This portfolio presents an overview of program vulnerabilities identified in prior Office of Inspector General (OIG) audits, evaluations, investigations, and legal actions related to chiropractic services in the Medicare program. It consolidates the findings and issues identified in ...
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 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 13th, 2018
New Modifiers Released in 2018
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 13th, 2018
There were 13 new modifiers released in 2018, be sure you are using them if appropriate.
FY
X-ray taken using computed radiography technology/cassette-based imaging
JG
Drug or biological acquired with 340b drug pricing program discount
QQ
Ordering professional consulted a qualified clinical decision support mechanism for this service and the related data was ...
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
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
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.
...
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 29th, 2018
Anesthesia Documentation Modifiers - Jurisdictions: J8A, J5A, J8B, J5B
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2018
Documentation Modifiers direct prompt and correct payment of the anesthesia claims submitted. Documentation modifiers (AA, QK, AD, QY, QX and QZ) must be billed in the first modifier field.
If a QS modifier applies, it must be in the second modifier field. Processing delays and denials may occur for claims submitted ...
January 29th, 2018
Anesthesia and Fee Calculation
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 29th, 2018 - Last Review/Update April 16th, 2020
Fees for anesthesia services are not calculated the same as for other types of procedures. There are four elements to consider when calculating anesthesia fees. Medicare accepts base units and time units; however, depending on the third party payer, they may or may not accept physical status units and/or qualifying circumstances units.
Base Unit (of the CPT code)
Time (in ...
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
What's the definition of an Office Visit and Can I Bill it With a Chiropractic Treatment?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published January 18th, 2018 - Last Review/Update February 4th, 2019
What is the definition of Office Visit? Can It be billed with a Chiropractic Treatment? What about using code 99123 E&M code for office visits? Can we bill of office visits even though we are giving chiropractic care?
January 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 16th, 2018
Patient Relationship Codes
By Wyn Staheli, Director of Research | Published January 16th, 2018
Section 1848(r)(4) of MACRA requires that claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, include codes for the following:
care episode groups
patient condition groups
patient relationship categories
Previously, CMS decided to use procedure code modifiers to report patient relationship codes on Medicare ...
January 15th, 2018
Medicare Requiring Specific Modifiers on Therapy Services
By Wyn Staheli, Director of Research | Published January 15th, 2018
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following:
Services furnished under the Outpatient ...
January 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
Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines
By Find-A-Code | Published January 11th, 2018
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1, 2010, non-covered services should be billed with modifier GA, GX, GY, or GZ, as ...
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
Should ROM Testing be Reported with Evaluation and Management Services?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 9th, 2018
Reporting the performance of range of motion testing (95851-95852) at the same encounter of an Evaluation and Management (EM) service, produces an NCCI edit resulting in payment for the EM service and denial of the ROM testing. Read the article to learn what other codes ROM testing is considered incidental to.
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 9th, 2018
Preventive Medicine with a New Patient
By Find-A-Code | Published January 9th, 2018
When coding for preventive care, be sure to use the correct encounter code with the procedure as well as the appropriate modifier if required.
New Patient: A patient that has not received any professional services i.e., E&M or any other face to face service from the physician or group within the ...
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
Acute Post-Operative Pain Management
By Find-A-Code | Published January 4th, 2018
CPT codes 62320, 62322 should be used when the analgesia is delivered by a single injection.These codes should only be used when the catheter or injection is not used for administration of anesthesia during the operative procedure. Modifier 59 should be used when billing these services to indicate that the catheter or injection was a ...
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
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
Billing Negative Pressure Wound Therapy (NPWT) (disposable device)
By Find-A-Code | Published January 4th, 2018
Per CMS: Disposable NPWT services are billed using the following Current Procedural Terminology® (CPT®) codes:
97607 - Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or ...
January 4th, 2018
Modifiers 54-55, split surgical and postoperative care
By Find-A-Code | Published January 4th, 2018
54 -Surgical care only; Surgeon is performing only the preoperative and intra-operative care
55 - Postoperative management only; Physician, other than surgeon, assumes all or part of postoperative care
Modifiers should be placed on the surgical code
Used on 10 day and 90 day surgical procedures
Both the surgeon and the physician providing the postoperative ...
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
Cleft Surgical Services
By Raquel Shumway | Published December 28th, 2017
Cleft palate and cleft lip diagnoses medical in nature and as such should be reported using the Current Procedural Terminology (CPT) codes instead of the Current Dental Terminology (CDT) codes. As such, Evaluation and Management (EM) services should be reported for the initial encounter with the patient and follow-up care ...
December 28th, 2017
Anesthesia
By Raquel Shumway | Published December 28th, 2017
Anesthesia services fall into one of the following categories ranging from lowest to greatest:
Local or topical anesthesia (not covered here)
Moderate (conscious) sedation (See “Moderate Sedation” on page xx)
Regional anesthesia
General anesthesia
Anesthesia is the administration of a drug or gas to induce partial or complete loss of consciousness. General anesthesia may only ...
December 28th, 2017
DME Documentation Requirements
By Wyn Staheli | Published December 28th, 2017
Properly documenting DME orders is crucial for reimbursement. It should be noted that without meeting the payer requirements, the claim will be denied. For Medicare, the beneficiary will not be responsible for paying for the item if the provider and/or supplier do not meet requirements. Commercial payers have similar policies so carefully ...
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
AT and GA Modifiers When Billing CMT and Non-covered Codes to Medicare
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published December 13th, 2017 - Last Review/Update February 5th, 2019
Questions regarding using modifiers when billing CMT and non-covered codes to Medicare. We have used AT (Active) and GA (signed ABN) when billing active care for CMT codes 98940-98942 (e.g., 98941-ATGA) in the past. Currently we are told not to bill GA with AT. How do we bill?
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 12th, 2017
THE EOB SAYS “BUNDLED” - NOW WHAT?
By Marge McQuade CMSCS, CHCI, CPOM | Published December 12th, 2017
Payers often bundle separate codes together so that they can pay you less. Just because the EOB says the codes are bundled doesn’t mean you have to let the insurance company get away with it. Fight Back!!! How does bundling work? If a patient presents for evaluation of diabetes, and...
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 ...
November 7th, 2017
Four Final Rules Affecting CMS Payments for 2018
By Wyn Staheli, Director of Research | Published November 7th, 2017
It’s a season for changes. CMS just finalized four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018
HHAs: Payment Changes for 2018
Quality Payment Program Rule for Year 2
This ...
October 31st, 2017
Modifier NU
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published October 31st, 2017 - Last Review/Update February 5th, 2019
Is it necessary to use the modifier NU for all supplies? or is NU part of the code itself? Where should the NU be noted on the 1500 form?
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 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 22nd, 2017
New Policy from UnitedHealthcare
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA | Published September 22nd, 2017 - Last Review/Update January 31st, 2018
In the June 2017 UHC Network Bulletin, there was an article that addressed UHC's decision to no longer pay for consultation services.....
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: 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 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 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 17th, 2017
Q/A: What are the Rules for a Fill-in (locum tenens) Doctor?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published August 17th, 2017 - Last Review/Update February 5th, 2019
A locum tenens provider is one that works in the place of the regular physician for a short duration of time. Guideline typically allows this time period to be a 60 day maximum, when a substitute doctor would be brought in to your office to cover your original doctor's actual schedule during the time he/she is absent.
Read further for more information
August 16th, 2017
If It’s Not a Consultation, What Is It?
By Omega Renne, CPC, CPCO, CPMA, CEMC, CIMC | Published August 16th, 2017
You thought you had a consultation supported in your documentation, and now you find out that you cannot bill the consultation codes (99241-99245, 99251- 99255). So, what are the top reasons for a consultation not to be supported?
If the payer does not support these codes
If the documentation does not support ...
August 4th, 2017
Proposed Telehealth Changes for 2018
By Wyn Staheli | Published August 4th, 2017 - Last Review/Update October 4th, 2017
Medicare has proposed making some changes to policies regarding telehealth services. They are adding some new codes to their covered list of telehealth services and propose eliminating the requirement to use the GT modifier. Since many payers adopt similar policies, watch for further announcements from other third-party payers.
Proposed Codes
HCPCS code G0296 ...
August 1st, 2017
Global Surgery
By Find-A-Code | Published August 1st, 2017 - Last Review/Update January 31st, 2018
The Medicare Learning Network provides guidance on the global surgical package
July 21st, 2017
Billing for Face-to-Face Counseling
By ChiroCode | Published July 21st, 2017 - Last Review/Update January 31st, 2019
Question: How should I bill for face-to-face Counseling time spent with the patient?
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 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 21st, 2017
Q/A: What Modifier Can I Use When Billing Massage Code 97124 With 97140?
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published June 21st, 2017 - Last Review/Update February 8th, 2019
Q. Can you tell me what modifier I can use when billing massage code 97124 with 97140? I was using -59, but I am not sure that is correct
June 13th, 2017
Modifier GY for Chiropractic
By ChiroCode | Published June 13th, 2017 - Last Review/Update January 31st, 2019
Q. Is there a modifier that can be added on to CPT codes to show we performed the service even though they are bundled charges or Medicare doesn't pay for them? For example 97140 billed to BCBS or 99202 billed to Medicare. Is the GY modifier for all insurance companies or just Medicare?
June 8th, 2017
Facet Joint Injections
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 8th, 2017 - Last Review/Update July 26th, 2017
Medicare will consider facet joint blocks to be reasonable and necessary for chronic pain (persistent pain for three (3) months or greater) suspected to originate from the facet joint. Facet joint block is one of the methods used to document and confirm suspicions of posterior element biomechanical pain of the ...
June 5th, 2017
Modifier 59
By Find-A-Code | Published June 5th, 2017 - Last Review/Update July 26th, 2017
Definition - The “-59” modifier is used to indicate a distinct procedural service. The physician may need to indicate that a procedure or service was distinct or independent from other services performed on the same day. This may represent a different session or patient encounter, different procedure or surgery, different site, ...
May 30th, 2017
GA and GY for Medicare Billing
By ChiroCode | Published May 30th, 2017 - Last Review/Update January 31st, 2019
We are using the ABN for non-covered services (such as therapy codes) when the patient is under active care. We are also using the ABN for CMT codes when the patient is under maintenance care. We are now confused about when to use the modifiers GA & GY when billing CMT & therapy codes. Would you please explain when & why each should be used for Active and Maintenance Care?
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.
May 4th, 2017
Therapy Caps, Limits and Providers
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 4th, 2017 - Last Review/Update July 26th, 2017
The annual combined therapy cap is per beneficiary each calendar year. For 2017, this includes Medicare Part B outpatient therapy cap for Occupational Therapy (OT) $1,980, Physical Therapy (PT) and Speech-Language Pathology Services (SLP) $1,980.
In addition there is an exception process, if the therapy services are higher than the limited amounts, the beneficiary ...
May 2nd, 2017
Plain Film Xray Penalty 2017
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published May 2nd, 2017 - Last Review/Update January 31st, 2019
Watch Another quick tip from the ChiroCode HelpDesk - Plain Film Xray Penalty 2017. Even though this news comes from Medicare, who does not reimburse chiropractic physicians for x-rays, private payers nearly always follow their example. This represents the trend of X-ray reimbursement for all of healthcare.
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 6th, 2017
Excluded from the Global OB Package
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 6th, 2017 - Last Review/Update July 28th, 2017
First three antepartum E&M visits
Laboratory tests
Maternal or fetal echography procedures (CPT codes 76801, 76802, 76805, 76810, 76811, 76812, 76813, 76814, 76815, 76816, 76817, 76820, 76821, 76825, 76826, 76827 and 76828)
Amniocentesis, any method (CPT codes 59000 or 59001)
Amniofusion (CPT code 59070)
Chorionic villus sampling (CPT code 59015)
Fetal contraction stress test (CPT code 59020)
Fetal non-stress test (CPT code 59025)
External cephalic version (CPT code 59412)
Insertion of cervical dilator (CPT code 59200) more than 24 hr before delivery
E&M services which is unrelated ...
March 13th, 2017
Reporting Unilateral Procedures
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 13th, 2017 - Last Review/Update July 28th, 2017
Some procedures are unilateral such as D7840-Condylectomy. It is important to consult with your payer on reporting requirements. Some payers require two separate line items with a LT or RT HCPCS Modifier, while others require only one modifier to be appended to the claim.
When billing a medical code for a Condylectomy, ...
March 3rd, 2017
Using Add-On Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 3rd, 2017 - Last Review/Update July 28th, 2017
There are certain procedures that are carried out in addition to the primary procedure called add-on codes. They describe a specific type of supplemental procedure done in addition that are labeled as add-on codes.
The AMA gives instructions and guidelines with notations such as "List separately in addition to primary procedure" or ...
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
Using Modifier EY
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017
Some Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items require a detailed Written Order Prior to Dispensing (WOPD), while others require a Detailed Written Order (DWO) prior to billing. The specific requirements for an order are specified in the Medical Policy (Local Coverage Determination and/or Policy Article) for the ...
February 23rd, 2017
Telehealth Growth Continues
By Wyn Staheli, Director of Research | Published February 23rd, 2017
Telehealth is proving to be the wave of the future as the number of practices offering these services continues to grow. An online poll by Medical Economics asked those who visited their site about the implementation of telehealth services implemented by their individual practices this year. As of February 2, 2017, the results were significant:
30% ...
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 22nd, 2017
Global Periods
By Wyn Staheli, Director of Research | Published February 22nd, 2017
What are the types of global periods?
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 6th, 2017
Q/A: Would Leaving Box 14 on the 1500 Claim Form Blank Cause Denials?
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published February 6th, 2017 - Last Review/Update February 8th, 2019
We have been leaving box 14 on the 1500 claim form blank for Medicare claims and are getting denials. Could this be why?
January 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
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) ...
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 21st, 2016
Covered colonoscopy is attempted but cannot be completed due to extenuating circumstances
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 21st, 2016 - Last Review/Update August 4th, 2017
Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure. However, the frequency standards associated with screening colonoscopies will not be applied by CWF. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to ...
December 21st, 2016
Q/A: E/M Bundled with CMT
By ChiroCode | Published December 21st, 2016 - Last Review/Update February 28th, 2019
What do you do when you are continually getting denials when billing office visit E/M code 99213-25 along with a CMT on dates that we do re-exams? What do you do when an appeal does not seem to work even though clear evidence has been provided that all conditions for the 99213 have been satisfied.?
December 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.
November 28th, 2016
Product Wastage Documentation Requirements and Reporting: Using JW Modifier
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 28th, 2016 - Last Review/Update August 1st, 2017
When using the JW modifier for Part B drug claims for discarded drugs and biologicals, any amount of wasted material should be clearly documented in the medical record with the following information:
Date, time, and location of treatment
Approximate amount of product unit used
Approximate amount of product unit discarded
Reason for the wastage
Manufacturer’s serial/lot/batch ...
November 28th, 2016
JW Modifier required, starting Jan. 01, 2017
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 28th, 2016 - Last Review/Update August 1st, 2017
Effective January 1, 2017, claims for discarded drugs or biologicals amount not administered to any patient shall be submitted using the JW modifier. Also, effective January 1st, 2017, providers must document the discarded drugs and biologicals in the patient's medical record.
A single use vial that is labeled to contain 100 ...
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 26th, 2016
Using Physical Status Modifiers with Anesthesia Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 26th, 2016 - Last Review/Update August 1st, 2017
These six levels are consistent with the American Society of Anesthesiologists (ASA) ranking of patient physical status. Physical status is included in the CPT codebook to distinguish among various levels of complexity of the anesthesia service provided.Example: 00100-P1Physical Status modifiers are represented by the initial letter ‘P’ followed by a single digit from 1 to 6 ...
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.
October 3rd, 2016
Upper Eyelid Blepharoplasty and Blepharoptosis Repair
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 3rd, 2016 - Last Review/Update August 1st, 2017
The Centers for Medicare & Medicaid Services (CMS) payment policy does not allow separate payment for a blepharoplasty procedure (CPT codes 15822, 15823) in addition to a blepharoptosis procedure (CPT codes 67901-67908) ontheipsilateral upper eyelid. Any removal of upper eyelid skin in the context of an upper eyelid blepharoptosis surgery is considered apart of ...
October 3rd, 2016
Upper Eyelid Blepharoplasty and Blepharoptosis Repair (update eff 10/01/2017)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 3rd, 2016 - Last Review/Update August 2nd, 2017
The Centers for Medicare & Medicaid Services (CMS) payment policy does not allow separate payment for a blepharoplasty procedure (CPT codes 15822, 15823) in addition to a blepharoptosis procedure (CPT codes 67901-67908) ontheipsilateral upper eyelid. Any removal of upper eyelid skin in the context of an upper eyelid blepharoptosis surgery is considered apart of ...
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 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 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...
August 3rd, 2016
How do I tell if a code is defined as unilateral or bilateral
By Codapedia | Published August 3rd, 2016
There are some procedures which are defined as unilateral procedures, and some defined as bilateral procedures. If the procedure is defined as unilateral but performedbilaterally, then the physician is paid 150% of the fee schedule amount when performed on both sides. If the code is defined as bilateral, there is...
July 29th, 2016
Preventive medicine and office visit, same day
By Codapedia | Published July 29th, 2016
Can I use modifier 25 on an E/M service on the same day as a preventive medicine exam Let’s review what a preventive medicine service is, in order to answer that question. Preventive medicine services are: • The description given by CPT® for “annual physicals” • Divided into new and...
July 29th, 2016
Hospice Care-Billing for physician services when a patient is on hospice
By Codapedia | Published July 29th, 2016
Patients who sign up with hospice waive their rights to receive Medicare Part B services, and must look to the hospice organization to provide care related to the terminal illness. The hospice provider receives a daily payment to care for the patient on hospice. The patient’s own attending physician, (who...
July 29th, 2016
Coding for pulmonary services
By Codapedia | Published July 29th, 2016
This is an overview of billing for services provided by Pulmonologists. Medicare recognizes Pulmonary Disease as a specialty. The resources section of this article contains the E/M Frequency data from CMS for the latest year available, and the fifty most commonly billed CPT® codes. What are the most common...
July 29th, 2016
Repeat Injections, Can I bill an E/M?
By Codapedia | Published July 29th, 2016
When reporting an office visit in conjunction with an injections/arthrocentesis we need to consider a few factors. First we need to be certain we are accurately applying modifier -25 which is required when a procedure is performed the same day as a procedure. In order to report modifier -25, the...
July 29th, 2016
Using denial tracking to improve collections
By Codapedia | Published July 29th, 2016
Here are some examples of denials that a practice should track to be sure that they are paid correctly by the insurance company. Set up a denial type for each of these. Fee Schedule Issues: Wrong amount paid per the contracted fee schedule. May be too high or too low...
July 29th, 2016
Modifier 25
By Codapedia | Published July 29th, 2016
Modifier 25: Significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service. Refer to the CPT® book for the complete definition. Modifier 25 is appended to the E/M service, never to a procedure. The decision about whether to bill for both...
July 29th, 2016
Modifier 22
By J. Paul Spencer, CPC, COC | Published July 29th, 2016 - Last Review/Update August 17th, 2017
Depending on a surgeon's area of expertise, documentation becomes an important tool not simply as a marker of care quality, but for the proper capture of charges and reimbursement. This past January 1st marked the 20th anniversary of CMS' adoption of Correct Coding Initiative (CCI) bundling edits, which have over ...
July 28th, 2016
QW Modifier for CLIA waived tests
By Codapedia | Published July 28th, 2016
QW is a HCPCS modifier defined as: CLIA waived test. Append it to lab services that are on the CLIA waived test list. Download the up to date list of CLIA waived tests from CMS's web site. The link is the citation. There are two issues: Some tests do not...
July 28th, 2016
Pre-op visits: True or False?
By | Published July 28th, 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 is going to take the...
July 28th, 2016
OIG Work Plan 2012-Do your own review of these areas
By | Published July 28th, 2016
The Office of Inspector General released its Work Plan for 2012. As in past years, the Work Plan describes the areas of interest that the OIG will investigate in the coming year. There are sections for hospitals, nursing homes, and of course, physicians. There is a pdf file attached to...
July 28th, 2016
Using Modifer -59
By Codapedia | Published July 28th, 2016
By Crystal Reeves, CPC, CMPE, Principal Modifier -59 is probably one of the most misunderstood, misused, and most-feared of all CPT® modifiers. Some practices avoid using it all together because they don’t want to be guilty of unbundling. Some practices do not use it because they are not at all...
July 15th, 2016
Compliance Plans: The Truth About Templates
By Sean Weiss, VP and Chief Compliance Officer at DoctorsManagement | Published July 15th, 2016 - Last Review/Update August 17th, 2017
This is not an article about building an effective compliance plan. It is about the most efficient and accurate way to build it and some of the nuances to be aware of when using a template to build your plan. As a compliance officer and someone that spends my days ...
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 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
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 7th, 2016
Multiple surgical procedures
By Codapedia | Published June 7th, 2016
Multiple Surgical Procedures In some groups, the coder performs all of the steps below. The responsibilities indicated here are opinion of the author, not law, regulation or national policy. Physician Responsibility: 1. List all codes for the procedures performed 2. Note whether the procedures performed were done via the same...
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 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 25th, 2016
The Use of Modifier 50
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 25th, 2016 - Last Review/Update August 4th, 2017
Modifier Review: Modifier -50
Modifier 50 is used to report a procedure performed bilaterally.
Example: The patient underwent bilateral tympanostomy with insertion of ventilating tubes.
If you look up the CPT code 69433, you will see it is a unilateral procedure and there are instructions telling you to append modifier -50 if it is ...
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.
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
Guidance For Modifier 24 Usage
By Sara San Pedro, CPC, CEMC, CPMA | Published March 4th, 2016
NAMAS Weekly Auditing and Compliance Tips Modifier 24 (Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period) has generated more scrutiny lately because of the attention it is receiving from Recovery Auditors and payors. An assignment of modifier 24 will oftentimes trigger a medical record...
March 4th, 2016
Guidance for Modifier 24 Usage
By Sara San Pedro, CPC, CEMC, CPMA | Published March 4th, 2016 - Last Review/Update August 16th, 2017
Modifier 24 (Unrelated Evaluation and Management Service by the Same Physician during a Postoperative Period) has generated more scrutiny lately because of the attention it is receiving from Recovery Auditors and payors. An assignment of modifier 24 will oftentimes trigger a medical record request, so we must be confident when ...
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
ABN is required - (if you anticipate payer will deny or is not medically necessary)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 3rd, 2017
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1st, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, ...
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
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 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...
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
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
Modifiers in Postoperative Periods
By Codapedia | Published January 6th, 2016
Modifiers in Postoperative Periods Introduction Documenting the events of a patient visit is not always the simplest and most straightforward of processes. Many variables affect which information must be included in order to report a procedure or service accurately. Global periods are one of those...
January 6th, 2016
Modifier 52 vs. 53 - What's the Difference?
By Codapedia | Published January 6th, 2016
So you’ve read the descriptions for both Modifiers 52 and 53, but you’re still on the fence as to which one is appropriate for a certain surgical case. This brief article will try to better differentiate between these two often-confused modifiers. Modifier 53...
January 6th, 2016
Minor Surgical Procedures - How to document and bill
By Codapedia | Published January 6th, 2016
When performing minor surgical procedures, it is important to document what was done, how it was done, where it was done, why it was done, how deep, how long, and how many. In billing and reporting a procedure, document in the medical record the key components...
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 6th, 2016
Coding Excisions and Wound Repairs
By Codapedia | Published January 6th, 2016
Chart audits frequently examine coding associated with lesion removals and wound repairs. In order to assign the appropriate procedure code, certain documentation must be included in the medical record, such as lesion type, excision size, wound repair, and location. Without these important details, providers...
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
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 18th, 2015
Class Finding Modifier Sheet
By Find-A-Code | Published December 18th, 2015 - Last Review/Update December 12th, 2018
Definition:
Modifier Q7: One Class A finding
Modifier Q8: Two Class B findings
Modifier Q9: Once class B and two class C findings
Appropriate Usage:
With foot care (podiatry) codes to indicate covered foot care
Inappropriate Usage:
One any code not related to foot care
When the foot care is for routine care, and not medically necessary
Class Findings
Class A Findings
Non ...
December 11th, 2015
CMS NCD drops clinical trial requirement for FDG PET scans for solid tumors
By Codapedia | Published December 11th, 2015
Patients no longer need to be in a CMS-approved clinical trial for physician practices to get paid for doing as many as four FDG PET scans for solid tumors – one for an initial treatment strategy and three to guide subsequent treatments, according to CMS...
December 11th, 2015
Hospital discharge, nursing facility admit billable on same day by same provider in most instances
By | Published December 11th, 2015
Medicare will typically pay for a hospital discharge service (billed with 99238-99239) and a nursing facility admission visit (99304-99306) when billed on the same date of service (DOS) by the same provider without the need for a modifier. As always, however, there are a couple...
December 11th, 2015
Modifier -24 - Indications for Use
By Codapedia | Published December 11th, 2015
Modifier 24 is used to indicate that an Evaluation and Management service was provided by the surgeon to a patient within the global period of a major or minor surgery. The claim must be accompanied by documentation that supports that the service is not...
December 11th, 2015
Billing for no-shows
By Codapedia | Published December 11th, 2015
CMS clarified in 2007 that a physician practice may bill Medicare patients for failing to keep an appointment. The CMS MedLearn matters article is attached as a resource. Check with your state Medicaid to see if you can bill Medicaid patients. If you are billing Medicare...
December 3rd, 2015
Post-operative Hospital Visits
By | Published December 3rd, 2015
In 1992, CMS developed the concept of the Global Surgical Package, which pays for surgical services with a single payment. The full description of services that are included in this payment is described in the Medicare Claims Processing Manual, Chapter 12, Section 40 and...
December 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 20th, 2015
Modifiers – Reimbursement or Informational? Modifier Training
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 5th, 2015
Reporting Laterality Still Requires Modifiers
By Wyn Staheli, Director of Research | Published October 5th, 2015
One of the significant coding changes with ICD-10-CM was including laterality within the code itself. This concept should help reduce billing errors and claim denials. Interestingly, CMS issued a statement regarding the reporting of laterality in their provider newsletter (emphasis added).
Implementation of ICD-10-CM will not change the reporting of Current Procedural Terminology ...
September 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 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 28th, 2015
ICD-10 Preparation for Pediatricians
By Daniel Schwartz | Published August 28th, 2015 - Last Review/Update February 3rd, 2017
Pediatricians are great at making boo-boos less painful for their patients, but without proper planning, they may not be able to alleviate the potential pains associated with the upcoming ICD-10 transition. What is ICD-10 Exactly and Why is This Transition Happening Now? Starting October 1st, providers will no longer be...
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
Compound Drugs - How to bill
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2015
Pharmacy compounding is a has been done for many years, it is a tradition that offers customized care to meet the specific needs of individual patients. Modern technology and innovative techniques with research have allowed more pharmacist to customize medication to meet a patients needs.
Through compounding, a prescriber and pharmacist can adjust ...
August 10th, 2015
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
Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2015 - Last Review/Update August 7th, 2017
Modifiers GN, GO, and GP refer only to services provided under plans of care for physical therapy, occupational therapy and speech - language pathology services. They should never be used with codes that are not on the list of applicable therapy services. For example, respiratory therapy services, or nutrition therapy ...
August 10th, 2015
Was Your Claim Denied as a Duplicate Service?
By | Published August 10th, 2015 - Last Review/Update January 27th, 2017
On occasion (if not more often), every practice receives a notice of claim denial that reads, ‘duplicate service.’ When the insurance denies a service as duplicate but your records indicate that is not true, how should you act?
First, gather all pertinent information on the claim to determine a possible cause. The following are some reasons why the ...
August 10th, 2015
Fill-in Doctor: Locum Tenens
By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017
It is a common practice for a solo doctor to find someone to cover for them while they are away from the office for a temporary or extended period of time, such as medical leave, or vacation. Some offices fail to code properly for the services rendered by the “fill-in” doctor. When completing the CMS 1500 ...
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
Specimen Drawing for Dialysis Patients (Rev. 3056, 12-01-14)
By Jared Staheli | Published July 10th, 2015
See the Medicare Benefit Policy Manual, Chapter 11, for a description of laboratory services included in the composite rate. With the implementation of the ESRD PPS, effective for claims with dates of service on or after January 1, 2011, all ESRD-related laboratory services are included in the ESRD PPS base ...
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
Technical Component (TC) of Physician Pathology Services to Hospital Patients (Rev. 2714, 06-25-13)
By Jared Staheli | Published July 10th, 2015
Section 542 of the Benefits Improvement and Protection Act of 2000 (BIPA) provides that the Medicare A/B MAC/carrier can continue to pay for the TC of physician pathology services when an independent laboratory furnishes this service to an inpatient or outpatient of a covered hospital. This provision applies to TC ...
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
Method of Payment for Clinical Laboratory Tests - Place of Service Variation (Rev. 2971, 07-07-14)
By Jared Staheli | Published July 9th, 2015
The following apply in determining the amount of Part B payment for clinical laboratory tests:
Laboratory tests not payable on the Clinical Diagnostic Laboratory Fee Schedule (CLFS) will be based on OPPS (for hospitals subject to OPPS) and current methodology for hospitals not subject to OPPS.
Independent laboratory or a physician or ...
July 9th, 2015
Paper Claim Submission to A/B MACs (B) (Rev. 3089, 01-01-15) - Billing for Clinical Laboratory Tests
By Jared Staheli | Published July 9th, 2015
An independent clinical laboratory may file a paper claim form shall file Form CMS- 1500 for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90.
An independent clinical laboratory that submits claims in paper format) may not combine non-referred ...
July 9th, 2015
Cases Involving Referral Laboratory Services (Rev. 1, 10-01-03)
By Find-A-Code | Published July 9th, 2015
If the specimen is drawn or received by an independent laboratory approved under the Medicare program that performs a covered test, but the lab refers the specimen to another laboratory in a different carrier jurisdiction for additional tests, the carrier servicing the referring laboratory retains jurisdiction for services performed by ...
July 9th, 2015
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
Automated Multi-Channel Chemistry (AMCC) Tests for ESRD Beneficiaries (Rev. 3116, 04-06-15)
By Jared Staheli | Published July 9th, 2015
Instructions for Services Provided on and After January 1, 2011
Section 153b of the MIPPA requires that all ESRD-related laboratory tests must be reported by the ESRD facility whether provided directly or under arrangements with an independent laboratory. When laboratory services are billed by providers other than the ESRD facility and ...
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
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 8th, 2015
Discarded Drugs and Biologicals (Rev. 1962, 07-30-10)
By Jared Staheli | Published July 8th, 2015
The CMS encourages physicians, hospitals and other providers and suppliers to care for and administer to patients in such a way that they can use drugs or biologicals most efficiently, in a clinically appropriate manner.
When a physician, hospital or other provider or supplier must discard the remainder of a single ...
July 8th, 2015
Discarded Erythropoietin Stimulating Agents for Home Dialysis (Rev. 1581; 12-01-08)
By Jared Staheli | Published July 8th, 2015
Multiuse vials are not subject to payment for discarded amounts of drug or biological, with the exception of self administered erythropoietin stimulating agents (ESAs) by Method I home dialysis patients. The renal facility must bill the program using the modifier JW for the amount of ESAs appropriately discarded if the ...
July 8th, 2015
Reporting Modifiers in the Compound Drug Segment (Rev. 1, 10-01-03)
By Jared Staheli | Published July 8th, 2015
Certain informational modifiers are required on compound ingredients. The NCPDP format does not currently support reporting modifiers in the compound segment. Therefore, the narrative portion in the prior authorization segment must be used to report these modifiers. The following must be entered in positions 001-003 of the narrative (Example, MMN ...
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
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
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
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 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
Modifier Requirements for Pre-diabetes (Rev. 457, 04-04-05)
By Jared Staheli | Published July 6th, 2015
A claim that is submitted for diabetes screening and the beneficiary meets the definition of pre-diabetes shall be submitted in the following manner:
The line item shall contain 82497, 82950 or 82951 with a diagnosis code of V77.1 reported in the header. In addition, modifier “TS” (follow-up service) – shall be ...
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
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
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
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 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;
• ...
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 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
Reporting the Ordering/Referring NPI on Claims for DMEPOS Items Dispensed Without a Physician’s Order (Rev. 1368, 04-07-08)
By Jared Staheli | Published June 18th, 2015
Chapter 5, section 5.2.1 of the Medicare Program Integrity Manual (PIM) states that, in order for Medicare to make payment for an item of Durable Medical Equipment Prosthetic, and Orthotic Supplies (DMEPOS), the DMEPOS supplier must obtain a prescription from the
For Coordination of Benefit purposes, DMEPOS suppliers shall use the ...
June 18th, 2015
DME MACs – Billing Procedures Related To Advanced Beneficiary Notice (ABN) Upgrades (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
This section provides the DME MACs billing instructions regarding the use of ABNs and claims modifiers for upgrades for items of DMEPOS.
Federal Regulations at 42 CFR 411.408 and Chapter 30 of this manual establishes the basis for a supplier to issue an ABN to a beneficiary. The purpose of the ...
June 18th, 2015
Providing Upgrades of DMEPOS Without Any Extra Charge (Rev. 2993, Upon Implementation of ICD-10)
By Jared Staheli | Published June 18th, 2015
Instead of using ABNs and charging beneficiaries for upgraded items, suppliers in certain circumstances may decide to furnish beneficiaries with upgraded equipment but charge the Medicare program and the beneficiary the same price they would charge for a nonupgraded item. The reason for this may be that a supplier prefers ...
June 18th, 2015
Billing for Oxygen and Oxygen Equipment (Rev. 1493; 04- 07-08)
By Jared Staheli | Published June 18th, 2015
The following instructions apply to all claims from providers and suppliers to whom payment may be made for oxygen. The chart in §130.6.1 indicates what is payable under which situation.
...
June 18th, 2015
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
Showing Whether Rented or Purchased (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 18th, 2015
Claims must specify whether equipment is rented or purchased. For purchased equipment, the itemized bill or claim must also indicate whether equipment is new or used. If the provider or supplier fails to indicate on an assigned claim whether equipment was new or used, the contractor processing the claims assumes ...
June 17th, 2015
DMEPOS Clinical Trials and Demonstrations (Rev. 2993, Upon Implementation of ICD- 10)
By Jared Staheli | Published June 17th, 2015
The definition of the QR modifier is “item or service has been provided in a Medicare specified study.” When this modifier is attached to a HCPCS code, it generally means the service is part of a CMS related clinical trial, demonstration or study.
The DME MACs shall recognize the “QR” modifier ...
June 17th, 2015
Elimination of Method II Home Dialysis (Rev. 2487, 06-19-12)
By Jared Staheli | Published June 17th, 2015
Effective for dates of service on and after January 1, 2011, Section 153b of the Medicare Improvements for Patients and Providers Act (MIPPA) eliminated Method II home dialysis claims. Specifically, Method II home dialysis is no longer recognized as a beneficiary option for dates of services beginning January 1, 2011, ...
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 17th, 2015
Payment for Replacement of Oxygen Equipment in Bankruptcy Situations (Rev. 1961, 10-04-10)
By Jared Staheli | Published June 17th, 2015
When a supplier files for Chapter 7 or 11 bankruptcy under Title 11 of the United States Code and cannot continue to furnish oxygen to its Medicare beneficiaries, the oxygen equipment is considered lost in these situations and payment may be made for replacement equipment. For replacement oxygen equipment, a ...
June 15th, 2015
General Inpatient Requirements (Rev. 1, 10-01-03)
By Find-A-Code | Published June 15th, 2015
HO-400, HO-400.G, HO-403, HO-412
The hospital may bill only for services provided. If the provider billing system initiates billing based on services ordered, the provider must confirm that the service has been provided before billing either the carrier or intermediary (FI).
The provider agreement to participate in the program requires the provider ...
June 15th, 2015
Carrier Jurisdiction of Requests for Payment (Rev. 2487)
By Find-A-Code | Published June 15th, 2015
Carriers have jurisdiction for all claims from the following:
• Physicians;
• Other individual practitioners;
• Groups of physicians or practitioners;
• Labs not part of a hospital;
• Ambulance claims submitted by ambulance companies under their own Medicare number (hospitals may operate ambulances as part of the hospital and bill the intermediary (FI));
• Ambulatory ...
May 11th, 2015
Modifier 33
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 11th, 2015 - Last Review/Update January 30th, 2017
Modifier 33 for Preventive Care
With the implementation of modifier 33 and its complicated and unique description, many coders have wondered how to properly apply it. Let's review the information we have on the modifier and see if we can better understand how and when to use it.
Modifier 33 was created ...
May 11th, 2015
How To Report Co-Surgeons and Assistant Surgeon Modifiers
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 11th, 2015 - Last Review/Update January 30th, 2017
Some surgeries require the expertise of more than one surgeon or may require the assistance of another surgeon to ensure adequate care is given and the surgery is a success.
Let's review a couple terms:
Co-Surgeon: When two surgeons act as primary surgeon for a specific procedure. Each acts as the primary surgeon ...
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, ...
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 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 26th, 2015
Codes for Coverage: Locum Tenens & Reciprocal Billing
By ChiroCode | Published February 26th, 2015 - Last Review/Update January 27th, 2017
Presenting Problem
Some doctors fail to code properly for a temporary doctor who is covering an office, or for mutual coverage with a colleague.
History/Subjective
It is a common practice for doctors in solo practice to find someone to “cover” for them while they are away from the office for a temporary or extended period of time.
During such ...
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 20th, 2015
Modifier Resource and Training Video
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 20th, 2015 - Last Review/Update February 18th, 2016
WPS Medicare developed these fact sheets to help you with your billing needs.
Informational Only Modifier Fact Sheet
Introduction to Modifiers
Pricing or Payment Modifier Fact Sheet
The Physician Fee Schedule Relative Value File Fact Sheet
Ranking Modifiers: Payment Modifier versus Informational Modifier
Ambulance Modifiers
Anesthesia Documentation Modifiers (AA, AD, QK, QX, QY, QZ)
Anesthesia Physical Status ...
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 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 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 28th, 2015
Modifier XU Fact Sheet
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 28th, 2015 - Last Review/Update August 8th, 2017
Unusual Non-Overlapping Service, The Use Of A Service That Is Distinct Because It Does Not Overlap Usual Components Of The Main Service
Coding pairs are part of the National Correct Coding Initiative (NCCI) procedure to procedure edits
Documentation indicates the service was not part of the usual components of the main service
Use Modifier ...
January 28th, 2015
Modifier XS Fact Sheet
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 28th, 2015 - Last Review/Update August 9th, 2017
Separate Structure, A Service That Is Distinct Because It Was Performed on A Separate Organ/Structure
Coding pairs are part of the National Correct Coding Initiative (NCCI) procedure to procedure edits
Documentation indicates the services were provided on different organs/structures
Use Modifier XS with the Column 2 procedure code in the NCCI files
Use Modifier XS only when there ...
January 28th, 2015
Modifier XP Fact Sheet
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 28th, 2015 - Last Review/Update August 9th, 2017
Separate Practitioner, A Service That Is Distinct Because It Was Performed By A Different Practitioner
Coding pairs are part of the National Correct Coding Initiative (NCCI) procedure to procedure edits
Documentation indicates the services were provided by different practitioners in the same group practice
Use Modifier XP with the Column 2 procedure code in the ...
January 28th, 2015
Modifier XE Fact Sheet
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 28th, 2015 - Last Review/Update August 9th, 2017
Separate Encounter, A Service That Is Distinct Because It Occurred During A Separate Encounter
Coding pairs are part of the National Correct Coding Initiative (NCCI) procedure to procedure edits
Documentation indicates the services were provided during separate patient/provider encounter
Use Modifier XE with the Column 2 procedure code in the NCCI files
Use Modifier XE only when there ...
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 ...
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
Modifier 50
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published November 21st, 2014 - Last Review/Update January 30th, 2017
Modifier Review: Modifier -50
Modifier 50 is used to report a procedure performed bilaterally.
Example: The patient underwent bilateral tympanostomy with insertion of ventilating tubes.
If you look up the CPT code 69433, you will see it is a unilateral procedure and there are instructions telling you to append modifier -50 if ...
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 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
Modifier 24
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 9th, 2014 - Last Review/Update January 30th, 2017
Modifier -24
When a patient is seen during a global (postoperative) period for something unrelated to the surgery for which the global period applies, modifier -24 is appended to the evaluation and management (EM) service.
The insurance may deny payment for the EM service; however, if the notes for that service ...
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 30th, 2014
Fill In Doctor: Locum Tenens
By | Published September 30th, 2014 - Last Review/Update January 30th, 2017
It is a common practice for a solo doctor to find someone to cover for them while they are away from the office for a temporary or extended period of time, such as medical leave, or vacation. Some offices fail to code properly for the services rendered by the “fill-in” ...
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
Fill In Doctor: Locum Tenens
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published July 31st, 2014 - Last Review/Update January 25th, 2017
It is a common practice for a solo doctor to find someone to cover for them while they are away from the office for a temporary or extended period of time, such as medical leave, or vacation. Some offices fail to code properly for the services rendered by the “fill-in” ...
July 31st, 2014
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 31st, 2014
Repeat Procedures on the Same Day - When to Report Modifiers -76 and -77
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 31st, 2014 - Last Review/Update January 25th, 2017
Have you ever had a claim deny as a ‘duplicate service’ only to find out upon further review that it was actually performed twice on the same day? This occurs more often than you realize and it is fairly easy to correct the error and get the claim paid. Modifiers ...
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 ...
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, ...
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 ...
July 8th, 2013
Denials for 97140 (Manual Therapy)? Here's the story.
By | Published July 8th, 2013 - Last Review/Update January 27th, 2017
The ChiroCode Institute has received several inquiries over the last few months regarding a denial for 97140 (Manual therapy—such as myofascial release or trigger point therapy) when billed with 98940-98942 (Chiropractic Manipulative Treatment - CMT) on the same visit. Most payers follow Medicare’s guidelines for the use of this code, ...
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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