"All Specialties" & "Training" Articles


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How to Search Find-A-Code for Medicare Policies and Guidelines — LCDs, NCDs and Articles —

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Help for Searching Find-A-Code when searching for Medicare Policies and Guidelines — LCDs, NCDs and/or Articles.

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

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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 ...

2021 Brings Another Risk Adjustment Calculation Change

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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...

Modifier 50 — Four "Must Know" Tips For Getting Paid

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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...

Are NCCI Edits and Modifiers Just for Medicare?

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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 ...

MEGA - NCCI Edit Changes - WHO Knew?

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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 ...

Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?

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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 ...

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

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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 - ...

Additional Telehealth Changes Announced by CMS

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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.

Clarify the Complexity Please! NDC Codes and Drug Classification Systems

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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 ...

Dismal OIG Report on Telemedicine

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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.

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

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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.

CMS Temporarily Suspends Contract-Level RADV Audits

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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.

CMS Announces Final 2021 HCC Risk Adjustment Changes

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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.

Financial Impact of CARES Act on Healthcare Providers

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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.

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

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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: ...

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

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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 ...

New HCPCS Code for Coronavirus Testing Announced

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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.

Inadequate Exclusion Screenings Could Put Your Practice at Risk

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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.

Denials due to MUE Usage - This May be Why!

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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 ...

Medicare Changes Bilateral Reporting Rules for Certain Supplies

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DME suppliers must bill bilateral supplies with modifiers RT and LT on separate claim lines or they are being rejected.

CMS says Codes are on the Move!

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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 ...

Hypertension ICD-10-CM Code Reporting Table

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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.

HIPAA Final Rule Eliminates HPID and OEID

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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.

And Then There Were Fees...

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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...

VA- Reasonable Charges Rules, Notices, & Federal Register

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Hypertension & ICD-10

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

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

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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 ...

Federal Workers Compensation Information

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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 ...

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

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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: ...

CMS and HHS Tighten Enrollment Rules and Increase Penalties

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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 ...

Are You Aware of Medicare Advantage Plans Timely Filing Rules?

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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 ...

How to Properly Report Prolonged Evaluation and Management Services

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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 ...

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

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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 ...

Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage

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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 ...

Are These Problems Hurting Your Practice?

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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.

Helping Others Understand How to Apply Incident to Guidelines

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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 ...

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

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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. ...

Small Breaches Can Be Subject to Large Penalties

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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 ...

Extrapolation Policies Apply to RAD-V Audits

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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 ...

A United Approach

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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 ...

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

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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 ...

How to Code Ophthalmologic Services Accurately

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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 ...

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

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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?

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

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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 ...

Medicare Revises Their Appeals Process

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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 ...

Medicare Revises Their Appeals Process

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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.

Let's Talk High Risk E/M Services

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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 ...

What is Medical Necessity and How Does Documentation Support It?

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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 ...

Prepayment Review Battle Plan

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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. ...

Q/A: Can I Tell a Medicare Patient Which Option to Check on the ABN?

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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 ...

Pain Codes in ICD-10-CM

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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 ...

Clearing Up Some Medicare Participation Misunderstandings

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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 ...

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

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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 ...

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

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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. ...

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

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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 ...

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

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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.

UnitedHealthcare to Discontinue Coverage of Consultations

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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).

Understanding NCCI Edits

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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 ...

Proposed Rule: Expanded Telemedicine Benefits for Medicare Advantage Beneficiaries

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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 ...

Coding Medicare Initial Preventive Physical Exams (IPPE)

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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 ...

Q/A: Do Digital X-rays Have Their Own Codes?

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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 ...

Clinical Staff vs. Healthcare Professional

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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 ...

Attestations Teaching Physicians vs Split Shared Visits

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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 ...

Empowering Medicare Beneficiaries

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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 ...

Medical Necessity vs. Documentation for Inpatient Services

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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 ...

Everything You need to Know about Drugs

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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 ...

How to Report Co-Surgeons Using Modifier 62

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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 ...

Are You Protecting Your Dental Practice From Fraud?

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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 ...

Dry Needling

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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 ...

CMS Finalizes Major Changes to ACO Program

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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 ...


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