"Health Care Reform" & "Topic Pages" Articles


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How CMS Determines Which Telehealth Services are Risk Adjustable

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Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.

Before Requesting a Review on Modifiers, Read This!

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Generally, there is uniformity in the use of modifiers between payers. However, this is not always the case; you may see a difference in payer policies and how modifiers are handled. One way to know if a modifier can be used according to CMS rules can be found when using ...

Correct Place of Service Codes are Not that Big of a Deal!

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Have you heard the saying, "I am getting paid, so I must be doing something right!" Claims get processed and paid incorrectly all the time; the fact is you may be doing something wrong even if you are getting paid! If you don't understand how the physician fee schedule works, ...

HHS Leaders Urge States to Maximize Efforts to Support Children’s Mental Health

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Today, agencies across the U.S. Department of Health and Human Services (HHS) issued a joint letter to states, tribes, and jurisdictions encouraging them to prioritize and maximize their efforts to strengthen children’s mental health and well-being. The letter, signed by leaders of the Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), the Administration for Children and Families (ACF), and the Administration for Community Living (ACL), outlines HHS’ plans to support and facilitate state-level coordination across federal funding streams to advance and expand mental health services for children.

E/M Changes Coming Our Way in 2023!

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Changes are one thing we can count on being consistent; even though this is one we have been anticipating, it is time to prepare, and we will have some work to do. The AMA released the new 2023 E/M Guidelines early to help us prepare for the change effective January ...

Sometimes it's the Little Coding Conundrums That Keep Us Concerned

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We all experience coding situations that make us stop and rethink our coding path. Do we have the most current information on this situation? Does the payer contract change the way we must report the service? Are we missing something? Each of us experience simple to complex coding issues in our work and sometimes it is just nice to collaborate and discuss them openly to see how they may be resolved. Have you ever questioned the proper use of major depressive disorder codes versus the newly added (2021) depression, unspecified code? Take a look at what the OIG said about these codes and how the payer responded.

Medicare Improper Payment Report — Chiropractic 2019 to 2021

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How did you do? Take a look at the Improper Payments Report and see where there can be improvement in your practice.

Q/A: Service Period for 99490

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Question:  If CCM hours/work is to be billed monthly, and CCM tasks are done daily throughout the month, should it be saved until the end of the month to bill, and should each date be billed as DOS in one claim? Answer:   According to CMS, “The service period for CPT 99490 ...

Reporting CCM and TCM Codes with E/M Codes

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When reporting CCM or TCM codes, you will only get reimbursed for what is allowed.  The E/M office visits can be coded in addition but are not interchangeable with CCM codes. You can bill an E/M visit during the time a patient is under Care Management, however, you can’t count time ...

How Much Do You Care about the 2022 Care Management Service Changes?

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Have you already implemented a care management services program in your provider organization? If not, now may be the time to seriously consider doing so. Significant 2022 changes to the codes and increases in RVUs and reimbursement rates creates an opportunity not only to improve patient care for chronic conditions but will also help your practice increase revenues if done correctly.

Preventive Medicine Versus E&M Codes: The Same-Day Coding Dilemma

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Choosing a proper office visit code can become confusing unless one understands the rules separating preventive medicine and evaluation and management (E&M) coding. Problem-oriented E&M services, office, and other outpatient visit codes 99202-99215 (along with hospital, observation, and consultative encounters) are for patients who present with signs, symptoms,...

Care Management Billing

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Chronic Care Management (CCM) is taking off, and with new codes and rules, it can get confusing. According to CMS, here are a few guidelines to help you with concurrent billing of CCM services. You can’t report complex CCM and non-complex CCM for the same patient in a calendar month Don‘t report ...

DMEPOS Items: Medical Record Documentation

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According to MLN Connects 2022-04-21 MLNC, "For Medicare to cover any Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) item, the patient’s medical record must include enough documentation to justify the need for: Type and quantity of items ordered Frequency of use (or replacement if applicable) The medical record should include the patient’s ...

Preventive Services

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In Today’s Take, let’s discuss the difference between preventive care. You might be thinking this is “101”. But it really isn’t. Oftentimes, when conducting chart audits, we not only we see issues with a lack of documentation criteria, especially with Medicare preventive services, but we also see confusion regarding...

$636 Million in Overpayments Made by Medicare to Providers for Neurostimulators

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According to the OIG "MEDICARE OVERPAID MORE THAN $636 MILLION FOR NEUROSTIMULATOR IMPLANTATION SURGERIES." So often we think if we get paid, we must be doing it right, well this is not always the case. You may get paid and then have to return the funds if billed incorrectly or a step ...

Split/Shared Visits No Longer Specific to Medicare Plans in 2022

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Medicare is making changes to the reporting guidelines for split or shared services. Some important changes have already gone into effect as of January 1, 2022 and others are scheduled to go into effect in 2023. If your organization reports split or shared services, it’s time to look more closely at how the new rules will affect your compliance policies and reimbursement.

Interpreting the VA's UCR Pricing

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Representing the methodologies used in the VA's pricing determinations is better understood coming directly from the source or an attorney who is familiar with the laws.  Our responsibility is to educate you with information directly from the source, where you can find your answers or contact them directly. We are happy to ...

Vaccine Mandates & Your Practice

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Staff vaccination requirements and who they apply to could greatly affect your organization. What does the Supreme court ruling mean for you.

Critical Care Services Changes in the Medicare 2022 Final Rule

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Critical Care Services — Medicare's final ruling has been released. This article discusses the changes to critical care services, including bundled services, concurrent services, global surgery, time spent performing CCS services, and documentation requirements. It also lists the two new modifiers.

PDPM Grouper for Skilled Nursing

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The additional grouper for Skilled Nursing, sometimes referred to as (PDPM), is used for classifying SNF patients in a covered Part A stay. This grouper is included with our Home Health Grouper.  Current groupers/calculators include: Home Health PDGM (Patient-Driven Grouping Model) Skilled Nursing Facility PDPM (Patient-Driven Payment Model) What is it? According to CMS, In ...

Müller Muscle Conjunctival Resection Versus External Levator Advancement

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Changes in RPM for 2021! Now, Wait for it... New RTM Codes for 2022

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Remote physiologic monitoring and clinical data monitoring is a relatively new concept thriving and growing as an essential component for telehealth services. According to global consumer trends, a company called Dynata reported, "Among the 39% of people who consulted a healthcare professional, two-thirds used telemedicine, many of them for the first time ...

Staging and Grading Periodontitis

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We now understand periodontitis may present itself as a manifestation of systemic diseases in fact; according to DeltaDental, research shows that more than 90 percent of all systemic diseases have oral manifestations, including swollen gums, mouth ulcers, dry mouth, and excessive gum problems. Some of these diseases include: Diabetes Leukemia Oral cancer Pancreatic cancer Heart ...

Summary of 2019 Changes to the ADA Dental Form

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In 2019 the ADA revised the ADA Dental claim form to incorporate editorial changes to further its consistency with the 837D. The previous update was in 2012, the changes in 2012 were made to incorporate the capability to report diagnoses codes.   Some of the important changes include Bx# 8 and 15, the description was updated ...

Dental-Provider Specialty Taxonomy Codes

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The National Uniform Billing Guidelines require the use of taxonomy codes for claims submissions on the ADA-Dental claim form and the CMS-1500 Medical Claim form. When reporting the taxonomy code, be sure the provider is contracted with the payer under the taxonomy code being reported. We have listed the general ...

Watch out for New ICD-10-CM Codes

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New ICD Codes for: Low Back Pain, Cervicogenic Headache, Non-Radiographic Axial Spondyloarthritis (nr-axSpA), and Social Determinations of Health (SDOH). These codes became effective on October 1, 2021.

​​Polysomnography Services Under OIG Scrutiny

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The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.” So what are those requirements?

Billing Dental Implants under Medical Coverage

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Implants can be costly to the patient and the provider, and it is crucial to understand how to bill a patient’s medical insurance to ensure there is adequate coverage for the best treatment. Implants are commonly billed in a dental office under a patient’s medical benefits.    Implants could be considered ...

New Codes for COVID Booster Vaccine & Monoclonal Antibody Products

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New codes have been announced for the COVID-19 booster vaccine, Novavax vaccine, and monoclonal antibody treatment.

Understanding How Place of Service Codes Work

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The Place of service (POS) codes are used by CMS, Medicaid, and other private insurance to indicate where medically related items and services are sold or dispensed for a patient. POS codes are used for professional billing and are required to be reported on each claim submitted on a CMS-1500 ...

How to Properly Assign ICD-10-CM Codes for Pain

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Pain is a common diagnosis among all specialties so it should not be surprising to find there are 162 ICD-10-CM codes for reporting it and over 80 mentions in the ICD-10-CM Official Guidelines for Coding and Reporting which describe when certain types of pain should be reported and how the codes should be sequenced.

Compliance in the Dental Office or Small Practice

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If your practice does not already have a compliance program in place, you will want to get started after reading this article. We have uncovered some important findings with the Office of Inspector General (OIG) in dental practices you need to be aware of. A compliance program offers standard procedures to follow, ...

UCR Anesthesia Fee Calculations and Base Units - Now Available!

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As per customer request, Find-A-Code now offers UCR Anesthesia Fee Calculations along with CMS and ASA. The anesthesia fee calculations can be found under the Fees section of the code and under the Anesthesia Fee Information.   Time units are computed by dividing the reported anesthesia time by 15 minutes (17 minutes / 15 minutes = 1.13 units). NOTE: Always ...

Important Changes to Shared/Split Services

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Reporting of split (or shared) services has always been wrought with the potential for incorrect reporting when the fundamental principles of the service are not understood. A recent CMS publication about these services further complicates the matter.

PCS Coding for Ankle Fracture - Look Deeper Into the Codes!

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If you're looking for ankle fractures in ICD-10-PCS, you may need to look a little deeper. Let's take a look at coding an ankle fracture such as a trimalleolar fracture. PCS coding can be confusing as it is nothing like CPT coding; with CPT we can simply code an ankle ...

Congress Has Been Busy — 11 Different Bills Pass Covering Mental Health and Substance Use

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The House of Representatives has certainly been working hard to advance behavioral health services. This article summarizes each of those bills and includes a link to contact your Senator.

Coding Lesions and Soft Tissue Excisions

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There are several considerations to be aware of before assigning a code for lesions and soft tissue excisions. The code selection will be determined upon the following: Check the pathology reports, if any, to confirm Morphology (whether the neoplasm is benign, in-situ, malignant, or uncertain) Technique Topography (anatomic location) The size Tissue Level Type of closure required Layers ...

58% of Improper Payments due to Medical Necessity for Ventilators

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Proper documentation not only protects the provider, the payer, and the patient, it protects the integrity of the entire healthcare system. When it comes to coverage and documentation for durable medical, the DMEPOS supplier and staff must be familiar with the National and Local Coverage Determinations (NCDs and LCDs) as these are ...

Properly Reporting Imaging Overreads (Including X-Rays)

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hile many provider groups offer some imaging services in their offices, others may rely on external imaging centers. When the provider reviews images performed by an external source (e.g., independent imaging center), that is typically referred to as an overread or a re-read. Properly reporting that work depends on a variety of factors as discussed in this article.

Understanding Skin Biopsy Codes

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A biopsy is a procedure to obtain only a portion of a lesion for a pathologic exam. According to the AMA, "The use of a biopsy procedure code (e.g., 11102, 11103) indicates that the procedure to obtain tissue for pathologic examination was performed independently, or was unrelated or distinct from other ...

Critical Evaluation and Management Changes Recently Announced by AMA

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On March 9, 2021, the American Medical Association (AMA) announced some pretty significant changes in relation to reporting Evaluation and Management (E/M) services, particularly for Office or Other Outpatient Services (99202-99215). The AMA Editorial Panel had previously met to discuss how to address concerns and made changes surrounding Office or Other Outpatient Services which are retroactive to January 1, 2021. Learn more about those changes in this article.

How To Properly Report Prolonged Services Using 99417 or G2212

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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 ...


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