"All Specialties" & "Risk Adjustment" Articles

Click on the title to see the article summary and a link to the full article.

February 22nd, 2021

COVID Vaccinations — FREE Legal and Ethical Considerations Webinar

By Wyn Staheli, Director of Research | Published February 22nd, 2021

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

February 17th, 2021

Why CMS Created G2212 for Prolonged Services Instead of 99417

By Wyn Staheli, Director of Research | Published February 17th, 2021 - Last Review/Update February 22nd, 2021

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

February 9th, 2021

Why Reporting E/M Based on Time May Not Be Beneficial

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 9th, 2021

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

February 3rd, 2021

How To Properly Report Prolonged Services Using 99417 or G2212

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 3rd, 2021

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

February 1st, 2021

New Procedure Codes for the Janssen COVID-19 Vaccine

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 1st, 2021

On January 19, 2021, the AMA announced two new CPT codes for reporting the Janssen Pharmaceutica (a division of Johnson & Johnson) COVID-19 vaccine. Of course, just as with the other COVID-19 vaccines, they must be given FDA approval for Emergency Use Authorization (EUA) to be administered before the codes can be reported. As is ...

January 21st, 2021

Looking Beyond an Employee's Coding Credentials

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 21st, 2021

In today's ever-changing healthcare environment, it is important that organizations hire coding and reimbursement personnel who enjoy learning. Each year changes are made in how healthcare services are coded and reported from federal and state laws, the code sets themselves, and varying payer policies. During the public health emergency (PHE) ...

January 11th, 2021

HIPAA Penalty Changes

By Wyn Staheli, Director of Research | Published January 11th, 2021

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

January 7th, 2021

CMS Reduces the Exchange User Fee to Support Lower Premiums for the Consumer

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 7th, 2021

It has been no secret that Americans have been complaining about the high cost of health plans since implementation of the Affordable Care Act (ACA). Premiums and deductibles have skyrocketed and in many states are equal to or exceed the cost of their rent or mortgage payments. As such, most ...

December 7th, 2020

Updated Stark Law and Anti-Kickback Statute Regulations Aimed at Improving Coordinated Care

By Jared Staheli | Published December 7th, 2020

The transformation of the American healthcare system from a primarily fee-for-service system to one based on value has been one of astonishing speed and scope, touching every aspect of health care. Changes of this scale inevitably have ripple effects that impact other laws and regulations, outdating them or highlighting inadequacies ...

November 24th, 2020

How Might the New 2021 E/M Guideline Changes Impact Risk Adjustment?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published November 24th, 2020

While provider organizations are busy learning the new E/M guideline changes being implemented January 1, 2021, Medicare Advantage Organizations (MAOs) are contemplating how the documentation changes for these services may impact risk adjustment coding. To be clear, the new E/M guidelines only pertain to Office and Other Outpatient E/M Services ...

November 5th, 2020

Are You Aware of the 2021 Star Rating System Updates?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published November 5th, 2020

Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues: Quality of ...

October 26th, 2020

Delving Into the 360 Assessment Fraud Complaint

By Jessica Hocker, CPC, CPB | Published October 26th, 2020

The Department of Justice is pursuing claims of healthcare fraud against Cigna Health-Spring Medicare Advantage plan based on how they used data from their 360 Program in 2012. A review of the allegations may help other payers avoid similar accusations.

October 22nd, 2020

Special Needs Plans Help Beneficiaries and Risk Adjustment Reporting

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 22nd, 2020 - Last Review/Update October 26th, 2020

October 12th, 2020

What is the Difference Between the Medicare 1995 and 1997 Documentation Guidelines for E/M Services?

By Aimee Wilcox | Published October 12th, 2020

When Medicare determined that providers could follow EITHER the 1995 OR the 1997 Documentation Guidelines for Evaluation and Management Services to determine which level of E/M service to report, because CMS had not clarified that portions of the 1995 and 1997 guidelines could be used together to determine the level of ...

August 27th, 2020

Is COVID-19 Causing Risk Adjustment “Gotcha’s”?

By Wyn Staheli, Director of Research | Published August 27th, 2020

The COVID-19 public health emergency (PHE) has created some possible problems when it comes to risk adjustment. Be sure your organization has implemented policies and procedures to try and overcome these new hurdles.

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

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 14th, 2020

New Name Same Great Product! "HCC Plus"

By Find-A-Code | Published July 14th, 2020

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 ...

June 4th, 2020

Proposed Risk Adjustment Changes

By Wyn Staheli, Director of Research | Published June 4th, 2020

On June 2, 2020, HHS published two proposed changes to the Risk Adjustment Data Validation (RADV) protocols for HHS-Operated Risk Adjustment Programs.

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 5th, 2020

ICD-10-CM - Supplement information for E-Cigarette/Vaping Reporting

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 5th, 2020

The CDC has released additional information and coding guidance for reporting encounters related to the 2019 health care encounters and deaths related to e-cigarette, or vaping, product use associated lung injury (EVALI). The update offers coding scenarios for general guidance, poisoning and toxicity, substance abuse and signs and symptoms. ICD-10-CM Official Coding Guidelines - ...

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 27th, 2020

Effective Risk Adjustment Requires Accurate Calculations

By Wyn Staheli, Director of Research | Published April 27th, 2020

Risk adjustment is simply a way of making sure that there are sufficient funds to adequately take care of the healthcare needs of a certain population. It’s a predictive modeling methodology based on the diagnoses of the individuals in that population. As payers move to value based models, they heavily rely on risk adjustment to ensure proper funding.

April 20th, 2020

Clarify the Complexity Please! NDC Codes and Drug Classification Systems

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 20th, 2020

Different Drug classification systems are used to categorize drugs to identify the medication, with each system having their own logic. There are four main drug classification systems used in the United States, not to be confused with a class of drugs or "Drug Class". A drug class is the way drugs ...

April 20th, 2020

Dismal OIG Report on Telemedicine

By Wyn Staheli, Director of Research | Published April 20th, 2020

Providers need to understand the rules for reporting telemedicine services. A recent OIG report shows that this is not the case. What problems are being found in documentation claims? As providers are expanding their telehealth offerings, now is the time to understand the potential pitfalls since disallowed amounts will be taken back.

April 16th, 2020

Hypertension ICD-10-CM Coding Table, Guidelines, and Tips

By Wyn Staheli, Director of Research & Aimee Wilcox, Director of Content | Published April 16th, 2020

Coding hypertension properly requires knowing all the guidelines. This article summarizes how hypertension is coded using ICD-10-CM and includes tips, definitions and a very helpful coding table summarizing your options.

April 15th, 2020

CMS Temporarily Suspends Contract-Level RADV Audits

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 15th, 2020

The Centers for Medicare and Medicaid Services (CMS) is suspending contract-level RADV audits, related to the payment year 2015 and will not initiate any new ones until after the public health emergency has ended. Any documentation already submitted will be reviewed as usual.

April 13th, 2020

CMS Announces Final 2021 HCC Risk Adjustment Changes

By Wyn Staheli, Director of Research | Published April 13th, 2020

On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) published their final Medicare Advantage (MA) and Part D payment methodologies for CY 2021. Read more to be prepared for these upcoming changes.

April 13th, 2020

Financial Impact of CARES Act on Healthcare Providers

By Wyn Staheli, Director of Research | Published April 13th, 2020

The recently enacted Coronavirus Aid, Relief, and Economic Security (CARES) Act has several provisions to ease the financial burden being faced by healthcare providers who have been impacted by the effect of the coronavirus. Learn more about how the Provider Relief Fund and the Accelerated and Advance Payment Program work.

March 24th, 2020

"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 24th, 2020

Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...

March 21st, 2020

Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2020

The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...

February 20th, 2020

New HCPCS Code for Coronavirus Testing Announced

By Wyn Staheli, Director of Research | Published February 20th, 2020 - Last Review/Update February 26th, 2020

Currently, healthcare providers testing patients for Coronavirus must use an unspecified code. To provide better tracking, on February 13, 2020, CMS announced the creation of a new HCPCS code.

January 21st, 2020

Inadequate Exclusion Screenings Could Put Your Practice at Risk

By Wyn Staheli, Director of Research | Published January 21st, 2020

Exclusion screenings require far more than just checking a name on a federal database at the time you are hiring someone. Far too many providers don’t realize that in order to meet compliance requirements, there is MUCH more involved. There are actually over 40 exclusion screening databases/lists that need to be checked.

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 ...

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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 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 ...

November 25th, 2019

Hypertension ICD-10-CM Code Reporting Table

By Wyn Staheli, Director of Research | Published November 25th, 2019

In ICD-10-CM, hypertension code options do not distinguish between malignant and benign or between controlled and uncontrolled. What is important for code selection is knowing if the hypertension is caused by or related to another condition. The following table shows some of these options.

November 12th, 2019

HIPAA Final Rule Eliminates HPID and OEID

By Wyn Staheli, Director of Research | Published November 12th, 2019

Final rule eliminates the requirement for health plans to obtain a unique health plan identifier (HPID) and also eliminates the voluntary use of the other entity identifier (OEID). This change becomes effective December 27, 2019.

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 21st, 2019

VA- Reasonable Charges Rules, Notices, & Federal Register

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 21st, 2019

October 7th, 2019

Hypertension & ICD-10

By Raquel Shumway | Published October 7th, 2019

Hypertensive Diseases and ICD-10. Helps and examples for these codes.

October 1st, 2019

2020 Official ICD-10-CM Coding Guideline Changes Are Here!

By Wyn Staheli, Director of Research | Published October 1st, 2019

It’s that time of year for offices to get ready for the ICD-10-CM code revisions. As part of that process, it’s also good to know what is going on with the ICD-10-CM Official Guidelines for Coding and Reporting. In the examples listed below, strikeout text is deleted and highlighted text ...

October 1st, 2019

Federal Workers Compensation Information

By Wyn Staheli, Director of Research | Published October 1st, 2019

When federal employees sustain work-related injuries, it does not go through state workers compensation insurance. You must be an enrolled provider to provide services or supplies. The following are some recommended links for additional information about this program. Division of Federal Employees' Compensation (DFEC) website Division of Federal Employees' Compensation (DFEC) provider ...

October 1st, 2019

The New ICD-10-CM Code Updates Are Here — Are You Ready?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 1st, 2019

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) A small revision in the description changed[STEC] to (STEC) for B96.21, B96.22, B96.23. Remember, in the instructional guidelines, ( ) parentheses enclose supplementary words not included in the description (or not) and [ ] brackets enclose synonyms, alternative wording, or explanatory phrases. Chapter 2: ...

September 30th, 2019

CMS and HHS Tighten Enrollment Rules and Increase Penalties

By Wyn Staheli, Director of Research | Published September 30th, 2019

This ruling impacts what providers and suppliers are required to disclose to be considered eligible to participate in Medicare, Medicaid, and Children's Health Insurance Program (CHIP). The original proposed rule came out in 2016 and this final rule will go into effect on November 4, 2019. There have been known problems ...

August 20th, 2019

Are You Aware of Medicare Advantage Plans Timely Filing Rules?

By Aimee Wilcox | Published August 20th, 2019

The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial. As any company who has billed Medicare services can attest, the one-year timely filing ...

August 13th, 2019

How to Properly Report Prolonged Evaluation and Management Services

By Aimee Wilcox | Published August 13th, 2019

Have you ever had a patient take more time with the provider than they were scheduled for? Do you understand which codes to report and the rules that govern them to allow for better reimbursement? Prolonged Service codes were created just for that reason but you must carefully follow the documentation ...

August 9th, 2019

The OIG Work Plan: What Is It and Why Should I Care?

By Namas | Published August 9th, 2019 - Last Review/Update August 14th, 2019

The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...

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 22nd, 2019

Are These Problems Hurting Your Practice?

By Wyn Staheli, Director of Research | Published July 22nd, 2019

There are many things that can be missed when trying to run an effective and profitable practice. This article covers some important tasks that are often overlooked such as not reviewing your payer contracts or failing to check eligibility.

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 27th, 2019

2018 Medicare Improper Payment Report Shows Slight Improvement but There's Still Work to be Done

By Wyn Staheli, Director of Research | Published June 27th, 2019 - Last Review/Update July 8th, 2019

The Medicare Improper Payment Report for 2018 is not a measurement of fraud. Rather, it is an estimate of the claims paid by Medicare which did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from July 1, 2016 through June 30, 2017, was 91.9 percent. ...

June 21st, 2019

Small Breaches Can Be Subject to Large Penalties

By Namas | Published June 21st, 2019 - Last Review/Update June 27th, 2019

Small Breaches Can Be Subject to Large Penalties We may have heard about the large fines issued by the Office for Civil Rights (OCR) against big organizations like Anthem or the University of Texas MD Anderson Cancer Center. These organizations have been in the news due to privacy breaches that constituted violations ...

June 17th, 2019

Extrapolation Policies Apply to RAD-V Audits

By Aimee Wilcox | Published June 17th, 2019

Risk Adjustment is a program that was implemented to identify and support Medicare beneficiaries with health conditions, illnesses, or injuries that put them at risk of death or organ system/bodily function failure. Through Risk Adjustment (RA), Medicare ensures their beneficiaries are being followed at least annually for any healthcare conditions ...

June 14th, 2019

A United Approach

By Namas | Published June 14th, 2019 - Last Review/Update June 18th, 2019

A United Approach As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...

June 13th, 2019

What Medical Necessity Tools Does Find-A-Code Offer?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019

Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...

June 6th, 2019

How to Code Ophthalmologic Services Accurately

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 6th, 2019 - Last Review/Update June 11th, 2019

Have you ever tried to quickly recall the elements required to support a comprehensive ophthalmologic exam versus an intermediate one? Make coding decisions quickly by creating a cheat sheet containing vital information that allows you to quickly select the right code. According to Article A19881 which was published in 2004 and ...

May 29th, 2019

Noting "Noncontributory" for Past Medical, Family, Social History - Is It Acceptable?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 29th, 2019 - Last Review/Update June 4th, 2019

Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?

May 21st, 2019

RT and LT Modifier Usage Change (effective 2019-03-01)

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 21st, 2019

According to Noridian Medicare, there are new changes required when reporting the RT and LT modifier(s). In the past, it was appropriate to bill the RT and LT modifier on the same line when it was required for certain HCPCS codes. Noridian released a publication stating claims reported with RT/LT on the same ...

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 23rd, 2019

Let's Talk High Risk E/M Services

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019

Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services. Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...

April 23rd, 2019

What is Medical Necessity and How Does Documentation Support It?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019

We recently fielded the question, “What is medical necessity and how do I know if it's been met?" The AMA defines medical necessity as: It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...

April 8th, 2019

Prepayment Review Battle Plan

By Wyn Staheli, Director of Research | Published April 8th, 2019

Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...

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 27th, 2019

Pain Codes in ICD-10-CM

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 27th, 2019

When coding with ICD-10-CM, pain codes can be found in different sections: The Body System affected or site-specific pain codes, such as Low Back Pain M54.5, can be found in Chapter 13. Diseases of the Musculoskeletal system (M00-M99). Other examples might be ocular pain H57.1, found in Chapter 7. Diseases of ...

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 22nd, 2019

Q/A: How do we Know Which Codes a Payer Will Allow?

By Wyn Staheli, Director of Research | Published March 22nd, 2019

How do we know which codes a payer will allow? The best way to determine the codes (CPT, ICD-10-CM and HCPCS) allowed by a payer is to review their payer policy. While it is good to know the official guidelines (e.g., ICD-10-CM Official Guidelines for Coding and Reporting, AMA Guidelines, Medicare ...

March 21st, 2019

The Impact of Medical Necessity on High Level E/M Services

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2019

I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?" The quick answer is, "it depends." Code 99233 has the following minimal component requirement: Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...

March 18th, 2019

How to Report Imaging (X-Rays) of the Thumb

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 18th, 2019

If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all ...

March 7th, 2019

Q/A: Can you Help me Understand the New Medicare Insurance Cards?

By Wyn Staheli, Director of Research | Published March 7th, 2019

As many of you are aware, CMS began issuing new Medicare identification cards last year which required the replacement of social security numbers with a new Medicare Beneficiary Identifier (MBI). All cards have now been mailed out and patient's should have the new cards when they come in. Currently, we are in the transition period until January 2020.

March 4th, 2019

UnitedHealthcare to Discontinue Coverage of Consultations

By Wyn Staheli, Director of Research | Published March 4th, 2019 - Last Review/Update March 7th, 2019

In United Healthcare's March provider bulletin, they announced that beginning on June 1, 2019, they will be phasing out coverage of consultation services (99241-99255).

March 1st, 2019

Understanding NCCI Edits

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 1st, 2019

Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...

February 14th, 2019

Proposed Rule: Expanded Telemedicine Benefits for Medicare Advantage Beneficiaries

By Aimee Wilcox | Published February 14th, 2019

Telemedicine continues its rise, with new technologies allowing for better communication and access to more aspects of healthcare than ever before. Each year Medicare has made strides, albeit small strides, in their telemedicine coverage while commercial payers continue to make great strides, constantly improving and expanding telemedicine service offerings to ...

February 12th, 2019

Coding Medicare Initial Preventive Physical Exams (IPPE)

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 12th, 2019

The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward. Purpose An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...

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 5th, 2019

Clinical Staff vs. Healthcare Professional

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 5th, 2019

State scope of practice laws and regulations will help determine who is considered Clinical staff and Other qualified Health Care professionals. Physician or other qualified healthcare professionals: Must have a State license, education training showing qualifications as well as facility privileges. Examples of Qualified Healthcare professionals: (NOTE: this list is not all-inclusive, please refer to your payer ...

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 25th, 2019

Medical Necessity vs. Documentation for Inpatient Services

By NAMAS | Published January 25th, 2019 - Last Review/Update January 29th, 2019

Auditing the documentation of inpatient and observation E/M services can often be challenging. Many of the notes we are provided for review include so much information that the note feels like a short novel instead of documentation for one date of service. This over-documentation can make it difficult to see ...

January 23rd, 2019

Everything You need to Know about Drugs

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 23rd, 2019

We have it all! Search our WK Drug Database for drugs and pharmaceuticals. When it comes to support and guidance the WK Drug Database offers a paramount search and is conveniently presented in one place. Pricing GPIs NDCs Billing Codes Indications/Diseases Packaging Information Active and Inactive and more... Additionally, learn more about drugs and pharmaceuticals that can be used to detect, treat, or monitor ...

January 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 10th, 2019

Are You Protecting Your Dental Practice From Fraud?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 10th, 2019

With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...

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 ...

November 29th, 2018

Errors Billing Outpatient Services When Patient is also Inpatient

By Wyn Staheli, Director of Research | Published November 29th, 2018

The OIG recently reported that Medicare inappropriately paid acute-care hospitals for outpatient services provided to patients who were inpatients of another facility including long term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and critical access hospitals. CMS suggests using the following resources to ensure compliance: Medicare Inappropriately Paid Acute-Care Hospitals for ...

November 28th, 2018

Q/A: Do Croft Guidelines Apply After Time has Passed Since the Accident?

By Tom Grant Jr. DC | Published November 28th, 2018

Question: Do the Croft Guidelines apply to a patient's condition immediately following the collision or are they applicable to a patient's state when they first come to see you? Whether that has been weeks or months since the collision without treatment?

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.

October 16th, 2018

Q/A: What Codes do I use for CLIA-Waived Tests?

By Wyn Staheli, Director of Research | Published October 16th, 2018

Question: I am a certified DOT medical examiner and have applied to get my CLIA lab (waiver) for urinalysis, finger prick blood tests for A1c, cholesterol and glucose. I realize I cannot diagnose patients with these tests, but I am using them to make decisions in the DOT process and with ...

October 1st, 2018

HCC - Acceptable Provider Interpretation for Diagnostic Testing

By Wyn Staheli, Director of Research | Published October 1st, 2018

The following table is taken from the Contract-Level Risk Adjustment Data Validation Medical Record Reviewer Guidance dated 2017-09-27 (see References). It is a listing of acceptable provider interpretation of diagnostic testing. Acceptable Examples include: Cardiology and Vascular Surgeons Echocardiogram (including Doppler, Duplex, Color flow of the heart vessels) EKG (electrocardiogram) – Stress test, Cardiac ...

September 12th, 2018

Join QPro Today and Get Certified

By Find a Code | Published September 12th, 2018

Join QPro Today and Get Certified! To have a credential in the medical profession shows you have met a minimum standard for professional and ethical standards. Often employers prefer to hire staff that will be involved with any type of patient information such as coding, to show proof they have met certain ...

August 31st, 2018

Finalized Confidentiality of Alcohol and Drug Abuse Patient Records Regulations

By Wyn Staheli, Director of Research | Published August 31st, 2018

In January, the U.S. Department of Health and Human Services (HHS) issued updates to the privacy regulations regarding the confidentiality of patient information of substance use disorder patients (42 CFR Part 2). This notice included references to better alignment with HIPAA regulations, but did state that Part 2 is more protective ...

August 20th, 2018

PSAVE Pilot Program - What Does it Mean to You?

By Wyn Staheli, Director of Research | Published August 20th, 2018

Noridian's pilot program Provider Self-Audit with Validation and Extrapolation (PSAVE) has been extended which means that it has been successful for the payer, which means that they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program. Are the benefits worth the costs?

August 16th, 2018

Medicare Timed Codes Guidelines

By Wyn Staheli, Director of Research | Published August 16th, 2018

Medicare's guidelines for reporting of timed codes is found in Medicare Claims Processing Manual Chapter 5, Section 20.2. Also known as the '8 minute' rule, it describes how to calculate time for appropriate reporting when more than one timed code is performed at the same time. It should be noted that while ...

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 12th, 2018

Q/A: Can You Swap Out 97140 with 97530?

By Wyn Staheli, Director of Research | Published July 12th, 2018 - Last Review/Update January 28th, 2019

Codes 97140 and 97530 are not interchangeable. See why.

June 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

VA Expands Telehealth

By Wyn Staheli, Director of Research | Published June 14th, 2018

On May 11, 2018, the Department of Veterans Affairs (VA) released its final rule on the "Authority of VA Health Care Providers to Practice Telehealth." Effective June 11, 2018, VA providers will be able to provide telehealth services across state lines. This move will make it easier for veterans to obtain ...

April 26th, 2018

Documenting DMEs

By Find-A-Code | Published April 26th, 2018

As per MLN MM8304, This article is based on Change Request (CR) 8304, which instructs DME MACs to implement requirements, which are effective July 1, 2013, for detailed written orders for face-to-face encounters conducted by the physician, PA, NP or CNS for certain DME items as defined in 42 CFR 410.38(g). Due to concerns ...

April 23rd, 2018

Q/A: Someone Broke into My Office. What do I do Now?

By Wyn Staheli, Director of Research | Published April 23rd, 2018 - Last Review/Update January 24th, 2019

My office was broken into last night. I use electronic health records, but we do store some protected health information for my patients in paper files. These files are not secured, so the burglars did have access to them. It did not appear that the files were touched as the burglars were looking for cash. What responsibilities to I have to my patients in a situation like this? Do I need to contact them and advise them that their PHI could have been compromised?

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 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 ...

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 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 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 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 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 Inpatient Rehabilitation Facilities

By Medicare Learning Network | Published March 8th, 2018 - Last Review/Update March 27th, 2018

The Medicare Learning Network provides guidance on required documentation for Inpatient Rehabilitation Facilities (IRF).

March 1st, 2018

New Bipartisian Budget Act of 2018 Provisions

By Wyn Staheli, Director of Research | Published March 1st, 2018

On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. There were some changes which will affect Medicare payments. The following is a brief summary, for a more comprehensive summary see the References. Therapy Caps: Some therapy caps (e.g., occupational, physical therapy, speech-language pathology) were discontinued. However, modifier KX will ...

February 28th, 2018

Telemedicine Billing and Reimbursement

By Jared Staheli | Published February 28th, 2018

The opportunities for providers who want to provide telemedicine continue to expand in all sectors of the healthcare market. Even the VA, long a symbol of a fossilized, bureaucratic healthcare entity, has begun to embrace this technology. Though most are familiar with what telemedicine is, many still have questions surrounding ...

February 23rd, 2018

The Comprehensive Error Rate Testing Program

By Frank Cohen, MBA, MPA | Published February 23rd, 2018 - Last Review/Update February 26th, 2018

With nearly a million physicians in this country, how do auditing organizations determine whom to audit?

February 21st, 2018

No HCPCS Code Available? Now What?

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 21st, 2018

HCPCS level II codes classify products into categories for the purpose of claims processing. HCPCS level II codes are alphanumeric with a descriptive terminology that identifies the item or service used primarily for billing purposes. There are several types of HCPCS level II codes such as: Permanent National Codes Dental Codes Miscellaneous Codes Temporary National ...

February 5th, 2018

HIPAA Breach Settlements and Ransomware Attacks - Is Your Practice Secure?

By Wyn Staheli, Director of Research | Published February 5th, 2018

Two recent reports should make providers stop, take notice and make sure their practice's policies and procedures are up-to-date. The first one involves a HIPAA Breach settlement of a company with facilities in several states. The OCR memo stated "In addition to a $3.5 million monetary settlement, a corrective action plan ...

February 2nd, 2018

Scoring & Reporting Your Audit Findings

By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published February 2nd, 2018 - Last Review/Update February 7th, 2018

This week we had a great question posted to our online forum, and I thought it would be a nice thought- provoking question for our auditing and compliance tip of the week.

February 1st, 2018

Are Your Computers Vulnerable to Cyber Attacks?

By Wyn Staheli, Director of Research | Published February 1st, 2018

Healthcare providers must be vigilant in ensuring that software upgrades, also known as patches, are kept current. Failure to do so can lead to a HIPAA Security Breach with all its associated penalties. For example Windows XP no longer has security updates and should not be used in healthcare settings. On ...

February 1st, 2018

OIG Reviews Medicare Advantage Claims

By Wyn Staheli, Director of Research | Published February 1st, 2018

On January 16, 2018, the OIG released a report of their findings on claims data for Medicare Advantage plans. While it appears that there were not significant issues, they did find that: "Types of potential errors included inactive or invalid billing provider identifiers; duplicated service lines; missing required data; inconsistent dates; ...

February 1st, 2018

Multiple Diagnostic Imaging Payment Reduction

By Wyn Staheli, Director of Research | Published February 1st, 2018

CMS and some other payers have adopted policies of reducing payments when certain multiple diagnostic imaging procedures (see Applicable Codes below) are performed in a single session by the same healthcare provider and/or group. They have done the same when there are multiple units for a procedure code. The rationale ...

January 31st, 2018

Adjusting Your Collection Strategies to HDHPs

By Ashley Choate | Published January 31st, 2018 - Last Review/Update March 29th, 2018

High Deductible Health Plans (HDHPs) are recent and growing trend in healthcare that is probably here to stay, regardless of the future changes to the national healthcare system or federal regulations.....

January 31st, 2018

Mobile Health: Growing Engagement and New Responsibilities

By Dugan Maddux, MD, FACP | Published January 31st, 2018 - Last Review/Update March 29th, 2018

This week I'm blogging about an M-word. Not MACRA or MIPS, but Mobile Health or mHealth....

January 29th, 2018

Referring and Ordering Physician - CMS-1500 Box 17

By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2018

Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in Item ...

January 29th, 2018

Aftercare Z Codes

By Find-A-Code | Published January 29th, 2018

Aftercare visit codes cover situations when the initial treatment of a disease has been performed, and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare Z code should not be used if treatment is directed at a current, ...

January 26th, 2018

Creating a Culture of Compliance in 2018

By Sean M. Weiss, CHC, CEMA, CMCO, CP MA, CPC-P, CMPE, CPC | Published January 26th, 2018 - Last Review/Update February 7th, 2018

This year (2018), health care organizations (Hospitals, Health Systems and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency....

January 24th, 2018

Better Office Communication Leads to Stronger RCM

By Ashley Choate | Published January 24th, 2018 - Last Review/Update March 29th, 2018

According to a recent Physicians Practice study, one of the top five reasons for denied medical claims is a lack of adequate documentation. While this might seem like an electronic records issue, the problem may be bigger than that. ...

January 24th, 2018

Revenue Cycle 101: Reduce your Denials with These Tips

By Ranadene Tapio, MBA, CMRS, CMC | Published January 24th, 2018 - Last Review/Update March 29th, 2018

Your practice seems to be doing everything right. You have a team in place, established your RCM process and you’re submitting claim after claim – but your denial rate isn’t going down....

January 24th, 2018

HIPAA and the Opioid Crisis

By Wyn Staheli, Director of Research | Published January 24th, 2018

HIPAA and the Opioid Crisis guidance released by HHS.

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 22nd, 2018

Compliance: What is it and Why is it Important

By Joan S. Hartman, RHIT | Published January 22nd, 2018 - Last Review/Update January 25th, 2018

Compliance. It is one of the buzz words in healthcare that is heard all the time but what is it really, and why is it so important?

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 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 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 3rd, 2018

Abuse, Neglect, or Maltreatment

By Wyn Staheli | Published January 3rd, 2018

According to the official ICD-10-CM Guidelines, in situations of maltreatment (e.g., adult and child abuse, neglect, etc.), the sequence of coding is important. Regardless of whether it is suspected or confirmed, it is important to document the type of abuse. Use the following sequence: An appropriate code from category T74- (confirmed) or T76- (suspected) Any accompanying mental ...

December 29th, 2017

Patient With Complex Needs

By Kelly Ogle, BSDH, MIOP, CMPM, CHOP | Published December 29th, 2017 - Last Review/Update January 31st, 2018

In each practice, there are patients who present with a multitude of problems. These problems can range from the smallest of symptoms to the more complex illnesses.....

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 15th, 2017

Is Your Practice in Need of a Wellness Visit?

By Valora Gurganious, MBA, CHBC | Published December 15th, 2017 - Last Review/Update January 31st, 2018

Is your practice busier than ever, but net practice income continues to drop?

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 8th, 2017

Quality Reporting and Payment Reduction

By ChiroCode | Published December 8th, 2017 - Last Review/Update January 30th, 2019

Checking my NPI number on the CMS site.

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.

December 1st, 2017

Auditing the Use of a Scribe

By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published December 1st, 2017 - Last Review/Update January 31st, 2018

A scribe is someone that can act as a walking transcriptionist on behalf of a medical provider......

November 30th, 2017

Coding Carpal Tunnel Syndrome

By Wyn Staheli, Director of Research | Published November 30th, 2017 - Last Review/Update February 5th, 2019

Q: In order to code carpal tunnel syndrome G56.01 or G56.02, does there need to be documentation that nerve conduction (EMG testing) has been performed to confirm the diagnosis?

November 24th, 2017

Inpatient critical care: When is it ok to question the medical necessity?

By Stephanie Allard, CPC, CEMA, RHIT | Published November 24th, 2017 - Last Review/Update January 31st, 2018

While critical care may be easily identifiable within documentation it is not always clear if it is medically necessary.....

November 17th, 2017

Fear Factor: "The Unethical Business of Medicine"

By Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC | Published November 17th, 2017 - Last Review/Update January 31st, 2018

I want this story that I am about to share with you to fit with the majority of clients that I represent and work with because I have represented clients with refund demands as small as $1,000 and clients who had demands greater than $30 million. This year has been ...

November 10th, 2017

The Importance of Attitude and Continuing Education

By Betty Stump, MHIA, RHIT, CPC, CCS-P, CPMA, CDIP | Published November 10th, 2017 - Last Review/Update January 31st, 2018

Coders, auditors, even physicians, and other healthcare professionals recognize their career paths will require ongoing education......

November 3rd, 2017

Auditing Medical Decision Making

By Grant Huang, CPC, CPMA | Published November 3rd, 2017 - Last Review/Update January 31st, 2018

With CMS looking to gradually revise its E/M documentation requirements to reduce the burden and complexity they pose to providers, it's a great time to review the trickiest E/M component: medical decision making (MDM)....

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 20th, 2017

PFSH Documentation: Q and A

By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published October 20th, 2017 - Last Review/Update January 31st, 2018

When coding an E/M visit in the emergency department, would you count all PFSH listed even if they don't pertain to the indication as to why the patient arrived?

October 18th, 2017

Physicians Reciprocal Billing Arrangements

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 18th, 2017

October 13th, 2017

So, How Do You Decide if a Service was Provided?

By David Glaser, JD | Published October 13th, 2017 - Last Review/Update January 31st, 2018

An earlier coding tip explained that the oft-repeated "if it isn't written, it wasn't done" is good risk management advice, but not a legal truism.....

October 6th, 2017

Acronyms and Abbreviations: When You Fall into the Grey Area

By Omega Renne, CPC, CPMA, CPCO, CEMC, CIMC | Published October 6th, 2017 - Last Review/Update February 1st, 2018

We've all been there... you are coding or auditing, and then a note comes up that is not like the ones you've reviewed before. The language is unclear, the acronym(s) could mean so many different things, and it's hard to get a straight answer about whether or not it's supported higher or lower....

September 29th, 2017

Stark Law for Healthcare Providers

By Brandy Brimhall, CPC, CMCO, CCCPC, CPCO, CPMA | Published September 29th, 2017

Be aware of physician self-referral laws and how they affect your practice.

September 29th, 2017

Big Data & Facility Audit Complex Reviews

By Shannon Cameron, MBA, MHIIM, CPC | Published September 29th, 2017 - Last Review/Update January 31st, 2018

Big data and its use in the healthcare spectrum has proven to be an incredible source of the knowledge and has rapidly abetted progress in seemingly all areas of healthcare......

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 15th, 2017

Copy and Paste: The Real Rules Prevail

By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA | Published September 15th, 2017 - Last Review/Update January 31st, 2018

Have you looked for published guidance on cloning/copying and pasting from the Centers for Medicare & Medicaid Services (CMS)? There is one published resource that provides rudimentary guidance.....

September 14th, 2017

Double Dipping in the History of the Evaluation and Management Note

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published September 14th, 2017

There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history. The subcomponents of history include: Chief Complaint ...

September 12th, 2017

Auditing Prolonged Evaluation and Management Services

By Aimee Wilcox | Published September 12th, 2017 - Last Review/Update September 18th, 2017

At times, there are patients who require prolonged face-to-face time with the provider to discuss or be counseled about their condition, plan of care, risks, complications, alternative therapies, or other medical issues. When E/M services go wild, taking significantly longer than the typical time associated with it, that direct face-to-face ...

September 12th, 2017

ICD-10-CM Coding Advice for Healthcare Encounters in Hurricane Aftermath

By BC Advantage | Published September 12th, 2017 - Last Review/Update January 25th, 2018

This document is intended to be used as a guide to help coding professionals when coding healthcare encounters of those individuals affected by a hurricane.

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

Abuse, Neglect, Maltreatment Coding Table

By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017

NOTICE: This table was created for use by those who have purchased a Find-A-Code specialty specific Reimbursement Guide. Please do not share with others. Codes in bold are complete codes of the highest specificity. Codes with ** are listed in the DSM-5 which contains diagnostic criteria. The underscore ( _ ) means that an ...

September 1st, 2017

Preventive Services: Alcohol Misuse Screening and Counseling

By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 5th, 2018

The following information from the Medicare Learning Network (MLN) provides guidance on Alcohol Misuse Screening and Counseling.......

September 1st, 2017

Preventive Services: 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: 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: 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: 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: 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....

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 23rd, 2017

Funding Extended for Veterans Choice Program

By Jared Staheli | Published August 23rd, 2017

The Veterans Choice Program, created in 2014, was part of the solution to the extensive waiting times found in the VA system. The program allowed veterans to meet their health care needs from private health care providers. Though the “sunset” of the program was avoided earlier in the year, the ...

August 23rd, 2017

VA Patient-Centered Community Care and Veterans Choice Program: Worth it for Providers?

By Jared Staheli | Published August 23rd, 2017

As the opportunities for providers outside the VA system expand in order to meet demand, you may be interested in offering services to veterans and the VA, if you are not already. With overwhelming bipartisan support, the opportunities are not likely to abate, but are those opportunities worth it for ...

August 18th, 2017

The Incredible Disappearing Consultation

By J. Paul Spencer, CPC, COC | Published August 18th, 2017 - Last Review/Update January 25th, 2018

In January of 2010, CMS ceased payment of CPT codes for consultations (99241 through 99245 for outpatient, and 99251 through 99255 for inpatient).

August 4th, 2017

Cybersecurity - Are you sure you are secure?

By Wyn Staheli, Director of Research | Published August 4th, 2017

An article by Medical Economics highlights the June report of the Health Care Industry Cybersecurity Task Force. Their report confirmed once again that healthcare providers are not adequately addressing cybersecurity as part of the compliance programs. The threat of hackers is very real and providers need to ensure that they have taken ...

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 4th, 2017

Veterans Choice Program

By Wyn Staheli | Published August 4th, 2017

In 2017, President Trump signed into law changes to the Veteran's Choice program, which allows veterans to seek care from a civilian (privately contracted) healthcare provider, closer to home, when obtaining care through the VA has become burdensome to the veteran or requires the veteran to wait too long for an appointment.

August 1st, 2017

HIPAA Training Requirements

By Wyn Staheli | Published August 1st, 2017 - Last Review/Update August 2nd, 2017

HIPAA Training must be an ongoing effort in every healthcare organization.

August 1st, 2017

Annual Wellness Visit (AWV)

By Wyn Staheli, Director of Research | Published August 1st, 2017

Annual Wellness Visits (AWVs) are a preventive medicine service. It is a comprehensive evaluation and management service which is covered by payers as part of the Affordable Care Act (ACA)'s covered services and there are typically no deductibles or co-pays.

August 1st, 2017

Global Surgery

By Find-A-Code | Published August 1st, 2017 - Last Review/Update January 31st, 2018

The Medicare Learning Network provides guidance on the global surgical package

July 28th, 2017

Auditing Vaccines

By Paul Chandler | Published July 28th, 2017 - Last Review/Update January 31st, 2018

Auditing vaccines can be difficult, as precise attention needs to be paid to the documentation to extract all variables needed for proper coding.

July 7th, 2017

Telemedicine: The Next Frontier in Care Delivery

By Valora Gurganious, MBA, CHBA | Published July 7th, 2017 - Last Review/Update January 25th, 2018

Technology is ubiquitous in modern society, and just when we thought that computers could not replace the "human touch" of a healthcare provider, technology is making specialized care accessible to patients anywhere there is an internet connection.

June 30th, 2017

NGS Medicare Releases New Audit Tool

By Liz Wilson, RHIT, CCS, CDIP, CPC, CRC, CEMC | Published June 30th, 2017 - Last Review/Update January 31st, 2018

Evaluation and Management (E/M) codes are defined by the AMA Current Procedural Terminology (CPT®) codebook and while they are the most commonly utilized CPT codes, their code descriptions have not changed in years.

June 16th, 2017

Got Drugs? Got Pricing?

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 16th, 2017

May 25th, 2017

Risk Adjustment Calculator (CMS-HCC Model)

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 25th, 2017

Risk Adjustments are used to access an illness or severity and comparing classifications of diseases using diagnosis codes. Find-A-Code gives you the ability to search for risk codes used for calculations on an individual code or calculator for a group of codes to quickly calculate a risk score. Keep in mind prior ...

May 25th, 2017

Bulk Risk Scores

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 25th, 2017

Do you need help with cases and calculating groups of Risk Scores? Per customers request, Find-A-Code now offers BULK entry for calculating for Risk Scores. The HCC Risk tool offers two options for calculating risk scores, we now offer a BULK calculation for cases or the calculation for a single enrollee. To use the BULK calculation for cases Create ...

April 10th, 2017

False Claim Penalties Increase Again

By Wyn Staheli, Director of Research | Published April 10th, 2017

On February 3, 2017, the Department of Justice (DOJ) issued a Final Rule to increase the civil monetary penalties assessed under the False Claims Act (FCA), due to inflation for the year 2017, to an all-time high of $10,957 (minimum) to $21,916 (maximum). Thirty years ago, in 1986, Congress amended the False ...

March 29th, 2017

E/M Table of Risk

By Wyn Staheli, Director of Research | Published March 29th, 2017

The final sub-component of Medical Decision Making is the Risk of Significant Complications, Morbidity and/or Mortality. The following is the official Evaluation and Management Table of Risk. The level is selected by choosing one element from three criteria (Presenting Problem, Diagnostic Procedures Ordered, and Management Options), with the highest level selected ...

March 2nd, 2017

Principal Diagnosis

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017

The official guidelines for ICD-10-CM have very specific rules in determining principal diagnosis. However, it is imperative to note that it is necessary to be aware of the coding conventions in the ICD-10-CM Tabular List and Alphabetic Index as they take precedence over the official coding guidelines. Also, consider the ...

March 2nd, 2017

Z Codes That May Only be Principal/First-Listed Diagnosis

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017

The following Z codes/categories may only be reported as the principal/first-listed diagnosis, except when there are multiple encounters on the same day and the medical records for the encounters are combined: Z00 Encounter for general examination without complaint, suspected or reported diagnosis Except: Z00.6 Z01 Encounter for other special examination without complaint, suspected ...

March 2nd, 2017

Insufficient Documentation

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017

When the medical documentation submitted is inadequate to support payment for the services billed, it may be determined that the claim contained insufficient documentation. If the claims reviewer is unable to conclude the services, some or all, were actually provided, they may determine the claim is unprocessable or incomplete. There are ...

March 2nd, 2017

Requirements for Physicians Orders for DME/HCPCS

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017

Effective July 1, 2013, certain DME/HCPCS codes require a valid detailed written order prior to delivery. There are very specific rules and requirements requiring medical necessity and orders/prescriptions. It is also required to keep a copy in the patients chart. If billing CMS and commercial payers payers, the DME prescribed ...

March 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 27th, 2017

How to Properly Dispose Protected Health Information (PHI)

By InstaCode Institute | Published February 27th, 2017

HIPAA requires covered entities to properly dispose of Protected Health Information (PHI) in the following manner: Paper, film, or other hard copy media has been shredded or destroyed such that the PHI cannot be read or otherwise cannot be reconstructed. Electronic media has been cleared, purged, or destroyed consistent with NIST Special Publication 800-88, Guidelines for Media ...

February 23rd, 2017

Physician Compensation Fraud Alert

By Wyn Staheli, Director of Research | Published February 23rd, 2017

In June 2015, the Office of Inspector General (OIG) issued a Fraud Alert focused on physicians and compensation arrangements. Providers need to ensure that these arrangements do not violate the Anti-Kickback Statute. Healthcare providers found to have committed fraud are subject to possible criminal, civil and administrative sanctions. In this alert ...

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 22nd, 2017

Global Periods

By Wyn Staheli, Director of Research | Published February 22nd, 2017

What are the types of global periods?

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 8th, 2017

Medicare Conversion Factor

By Wyn Staheli, Director of Research | Published February 8th, 2017

In April of 2015, the Sustainable Growth Rate (SGR) formula which is used to calculate the Medicare Physician Fee Schedule (MPFS) Conversion Factor was repealed as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The conversion factor will increase by 0.5% each year until 2019 and ...

February 6th, 2017

Medicare Revises their Appeals Process

By Wyn Staheli, Director of Research | Published February 6th, 2017

On January 17, 2017, a Final Rule was published in the Federal Register outlining changes to the Medicare Appeals process in an order to streamline procedures and reduce the current backlog of appeals at the third and fourth levels of appeal. This new policy takes effect on March 20, 3017. ...

February 6th, 2017

Medicaid EHR Incentive

By Wyn Staheli, Director of Research | Published February 6th, 2017

The Medicare and Medicaid incentive programs are different. The Medicare EHR incentive program has been incorporated into the new Quality Payment Program (QPP). However, providers may be unaware that there is still a Medicaid EHR incentive program. The time period for signing up for the Medicaid EHR incentive program ended in 2016. ...

February 2nd, 2017

Psychotherapy Notes Provision of HIPAA

By Wyn Staheli, Director of Research | Published February 2nd, 2017

Of special interest to all behavioral health practitioners (both Covered Entities and NON-covered entities) is HIPAA's provision for psychotherapy notes. The privacy rule recognizes that psychotherapy notes need more protection than other types of PHI. Even if you are not a covered entity, we recommend understanding and implementing office procedures ...

January 31st, 2017

Clinical Scenario for Coding with ICD-10-CM: Abdominal Pain

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 31st, 2017 - Last Review/Update August 2nd, 2017

Chief Complaint • “My stomach hurts and I feel full of gas.” History • 47 year old male with mid-abdominal epigastric pain, associated with severe nausea & vomiting; unable to keep down any food or liquid. Pain has become “severe” and constant. • Has had an estimated 13 pound weight loss over the past ...

January 24th, 2017

Code Sets - Health Care Provider Taxonomy Code Set Link

By Raquel Shumway | Published January 24th, 2017

Every Provider needs to know their Health Care Provider Taxonomy Codes. The Taxonomy Codes define the provider type, classification, and area of specialization. We have provided a link and instructions to help you locate your code.

January 23rd, 2017

New and Deleted Drug Screen codes for 2017

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 23rd, 2017 - Last Review/Update March 8th, 2017

Deleted Codes for Drug Screening, the following codes are no longer valid for services performed on or after January 01, 2017. Deleted Codes for 2017 80300 Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (eg, immunoassay) capable of being read by direct optical ...

January 16th, 2017

Alternative Payment Models (APMs) and Advanced APMs

By Wyn Staheli, Director of Research | Published January 16th, 2017

When CMS Released the NPRM regarding the Quality Payment Program (QPP), it included two payment tracks: MIPS and Advanced Alternative Payment Models (APMs). Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs. So how do these payment models differ? According to a fact sheet ...

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 13th, 2016

Health Risk Assessment

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 13th, 2016

Risk Adjustment models are used to calculate risk scores used in predicting average beneficiaries healthcare expenditures. Currently Medicare Advantage and Prescription Drug programs include a risk adjustment as a component of the bidding and payment process to standardize bids, compare bids, and adjust plan payments. If you are not familiar ...

December 12th, 2016

60 Day Final Rule

By Wyn Staheli, Director of Research | Published December 12th, 2016

Effective March 14, 2016, the CMS Final Rule clarifying the standards for handling overpayments for both Medicare and Medicaid takes effect. Failure to report and subsequently return an overpayment within 60 days after the overpayment was “identified” is a violation of the False Claims Act.

December 7th, 2016

Workers Compensation

By Wyn Staheli, Director of Research | Published December 7th, 2016

Workers’ Compensation is for work related illness or injuries on the job. The employer pays for insurance which covers medical costs incurred, and replaces lost wages. Fees are based on a specific fee schedule that varies by state. There are three possible scenarios regarding workers’ compensation: the patient is covered by ...

December 7th, 2016

Discounts

By Wyn Staheli, Director of Research | Published December 7th, 2016

All healthcare providers need to be aware that there are both appropriate and inappropriate ways to discount your fees. Both state and federal laws can impact your practice financial policy regarding fee discounts. Additionally, we recommend carefully reviewing either Chapter 1.5-Fees of the Behavioral Health DeskBook or the Insurance and Reimbursement chapter ...

December 2nd, 2016

Risk Adjustment and Hierarchical Condition Category Coding and Auditing

By Michelle West, CPC, CEMC, CPMA, CRC | Published December 2nd, 2016 - Last Review/Update August 17th, 2017

Risk Adjustment (RA) and Hierarchical Condition Category (HCC) coding is a payment model mandated by CMS in 1997, which was implemented in 2003. This model identifies individuals with serious or chronic illness and assigns a risk factor score to the person based upon a combination of the individual's health conditions ...

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 ...

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 ...

August 30th, 2016

Documenting injuries

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 30th, 2016

ICD-10 expands sections on poisonings and toxins. When documenting injuries, include the following: 1. Episode of Care e.g. Initial, subsequent, sequelae 2. Injury site Be as specific as possible3. Etiology How was the injury sustained (e.g. sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)?4. Place ...

August 30th, 2016

Documentating Diabetes Mellitus, Hypoglycemia and Hyperglycemia

By Find-A-Code | Published August 30th, 2016

The Increased Specificity in ICD-10-CM means documentation must more specific to accommodate the complications and combinations used. The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.When documenting diabetes, include the following:1. Type e.g. Type 1 ...

August 23rd, 2016

Smoking and tobacco cessation counseling, covered indications and # of visits

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 23rd, 2016 - Last Review/Update August 2nd, 2017

Nationally Covered Indications:Effective for claims with dates of service on or after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries1. Who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;2. Who are competent and alert at the time that ...

August 3rd, 2016

Billing Units

By Wyn Staheli, Director of Research | Published August 3rd, 2016

Are you billing units correctly? This article outlines important considerations to ensure that claims are submitted properly.

June 21st, 2016

Voluntary Overpayments

By Wyn Staheli, Director of Research | Published June 21st, 2016

When a claim has been determined to be paid more than the allowed amount, it is considered an overpayment. The action to be taken depends on how the overpayment is discovered. This article covers voluntary overpayment refund procedures as well as a Voluntary Overpayment Form.

June 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

Understanding and Using Taxonomy Codes to Maximize Reimbursement

By | Published June 9th, 2016

Taxonomy codes are used by insurers as indicators of legal scope of practice. Scope of practice is key to getting reimbursed under the Affordable Care Act or ObamaCare. However, Most providers will only choose one taxonomy code to describe their training. This limits their scope of practice. To maximize scope ...

March 4th, 2016

What is an 'Other Qualified Healthcare Professional'?

By Wyn Staheli | Published March 4th, 2016

What's the difference between a physician, an other qualified healthcare professional, clinical staff and individual.

February 24th, 2016

Employee Exclusions Screenings Must be High Priority

By Wyn Staheli | Published February 24th, 2016

Many healthcare organizations are not aware of how critically important it is to screen their employees against ALL state and federal exclusions databases. This article has important information for organization to ensure compliance.

February 1st, 2016

Will Incident-To in Your Organization Pass a Compliance Audit?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 1st, 2016

Practices that bill incident to services need to periodically audit compliance with Medicare and private payor guidelines to avoid potential denials or third-party audits.

January 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...

October 5th, 2015

Reporting Laterality Still Requires Modifiers

By Wyn Staheli, Director of Research | Published October 5th, 2015

One of the significant coding changes with ICD-10-CM was including laterality within the code itself. This concept should help reduce billing errors and claim denials. Interestingly, CMS issued a statement regarding the reporting of laterality in their provider newsletter (emphasis added). Implementation of ICD-10-CM will not change the reporting of Current Procedural Terminology ...

September 11th, 2015

Essential Health Benefits (EHBs)

By Wyn Staheli, Director of Research | Published September 11th, 2015 - Last Review/Update February 25th, 2016

Information about the mandated Essential Health Benefits (EHBs). Includes links and other helpful information.

August 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 ...

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 ...

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 7th, 2015

Personal Injury Information by Find-A-Code

By Find-A-Code | Published May 7th, 2015 - Last Review/Update June 9th, 2016

Personal Injury is an complicated subject as it relates to medical services. This page contains helpful information as an additional resource to Find-A-Code's specialty-specific Reimbursement Guides.

March 17th, 2015

Patient Information Form

By Raquel Shumway | Published March 17th, 2015 - Last Review/Update June 9th, 2016

We have two different samples for Patient Information Forms. We suggest that you review both and determine which best fits your practice model. Form #2 is editable so it could be easily modified for your organization. Both forms provide the basic information necessary for all types of healthcare practices. Instructions for: Patient ...

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

Health Care Reform

By Wyn Staheli, Director of Research | Published February 3rd, 2015 - Last Review/Update June 9th, 2016

Even though the health care system in the United States is one of the most expensive per capita in the world, we have a dismally low quality of care ranking. Healthcare reform (HCR) in its simplest terms is addressing these shortcomings in order to improve healthcare coverage, delivery, policies, or ...

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:

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

Compliance Specialists

By | Published September 9th, 2014

Compliance specialists are responsible for monitoring health and human services program operations for compliance with federal and state regulations and standards in order to promote health and safety, assure that public services are delivered properly, or prevent fraud. Areas assessed may include service delivery, eligibility determination and payment, medical reimbursement, ...

August 26th, 2014

Q & A: What is the Definition of "New Patient" for Billing Evaluation and Management (E/M) Services?

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 26th, 2014 - Last Review/Update August 9th, 2017

Q: What is the definition of "new patient" for billing evaluation and management (E/M) services? A: Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice ...

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.Â Â We have given you some basic information to get you started including modifiers and how CMS views DMEPOS, please ...

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” ...

January 1st, 2014

Testing & Screening Tools

By Wyn Staheli, Director of Research | Published January 1st, 2014 - Last Review/Update October 4th, 2017

There are numerous types of behavioral health screening tools for healthcare providers. Some, like the AUDIT and SBIRT are especially applicable to primary care providers caring for Medicare beneficiaries. This page includes some general information and resources for some of these screening tools. Let us know if you would like others included ...

September 29th, 2012

Privacy Rule De-Identifiers

By | Published September 29th, 2012 - Last Review/Update January 27th, 2017

The HIPAA Privacy Rule provides two ways to de-identify information, which are listed here with the 18 de-identifiers.

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