"Compliance" & "Topic Pages" & "OSHA" Articles


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

HIPAA Penalty Changes

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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.

ICD-10-CM 2021 Codes for your Specialty

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1. Certain infectious and parasitic diseases (A00-B99) Code:            Description:A84.81          Powassan virus diseaseA84.89          Other tick-borne viral encephalitisB60.00          Babesiosis, unspecifiedB60.01          Babesiosis due to Babesia microtiB60.02          Babesiosis due to Babesia duncaniB60.03        ...

ICD-10-CM 2021 Codes for your Specialty

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13. Diseases of the musculoskeletal system and connective tissue (M00-M99) Code:            Description:M05.7A          Rheumatoid arthritis with rheumatoid factor of other specified site without organ or systems involvementM05.8A          Other rheumatoid arthritis with rheumatoid factor of other specified siteM06.0A        ...

ICD-10-CM 2021 Codes for your Specialty

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15. Pregnancy, childbirth and the puerperium (O00-O9A) Code:            Description:O34.218        Maternal care for other type scar from previous cesarean deliveryO34.22          Maternal care for cesarean scar defect (isthmocele) O99.891        Other specified diseases and conditions complicating pregnancyO99.892        Other ...

ICD-10-CM 2021 Codes for your Specialty

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16. Certain conditions originating in the perinatal period (P00-P96) Code:            Description:P91.821         Neonatal cerebral infarction, right side of brainP91.822         Neonatal cerebral infarction, left side of brainP91.823         Neonatal cerebral infarction, bilateralP91.829         Neonatal cerebral infarction, unspecified side ...

ICD-10-CM 2021 Codes for your Specialty

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18. Symptoms, signs and abnormal clinical and laboratory findings, not elsewhere classified (R00-R99) Code:            Description:R51.0            Headache with orthostatic component, not elsewhere classifiedR51.9            Headache, unspecifiedR74.01          Elevation of levels of liver transaminase levelsR74.02     ...

ICD-10-CM 2021 Codes for your Specialty

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19. Injury, poisoning and certain other consequences of external causes (S00-T88) Code:            Description:S20.213A      Contusion of bilateral front wall of thorax, initial encounterS20.213D      Contusion of bilateral front wall of thorax, subsequent encounterS20.213S      Contusion of bilateral front wall of thorax, sequelaS20.214A      Contusion of ...

ICD-10-CM 2021 Codes for your Specialty

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20. External causes of morbidity (V00-Y99) Code:            Description:V00.031A       Pedestrian on foot injured in collision with rider of standing electric scooter, initial encounterV00.031D       Pedestrian on foot injured in collision with rider of standing electric scooter, subsequent encounterV00.031S       Pedestrian on foot injured ...

ICD-10-CM 2021 Codes for your Specialty

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21. Factors influencing health status and contact with health services (Z00-Z99)    Code:            Description:Z03.821         Encounter for observation for suspected ingested foreign body ruled outZ03.822         Encounter for observation for suspected aspirated (inhaled) foreign body ruled outZ03.823         Encounter for ...

ICD-10-CM 2021 Codes for your Specialty

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14. Diseases of the genitourinary system (N00-N99) Code:            Description:N00.A            Acute nephritic syndrome with C3 glomerulonephritisN01.A            Rapidly progressive nephritic syndrome with C3 glomerulonephritisN02.A            Recurrent and persistent hematuria with C3 glomerulonephritisN03.A          ...

ICD-10-CM 2021 Codes for your Specialty

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11. Diseases of the digestive system (K00-K95) Code:            Description:K20.80          Other esophagitis without bleedingK20.81          Other esophagitis with bleedingK20.90          Esophagitis, unspecified without bleedingK20.91          Esophagitis, unspecified with bleedingK21.00          Gastro-esophageal reflux disease with esophagitis, ...

ICD-10-CM 2021 Codes for your Specialty

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10. Diseases of the respiratory system (J00-J99) Code:            Description:J82.81           Chronic eosinophilic pneumoniaJ82.82           Acute eosinophilic pneumoniaJ82.83           Eosinophilic asthmaJ82.89           Other pulmonary eosinophilia, not elsewhere classifiedJ84.170         Interstitial lung disease with ...

ICD-10-CM 2021 Codes for your Specialty

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7. Diseases of the eye and adnexa (H00-H59) Code:            Description: H18.501        Unspecified hereditary corneal dystrophies, right eyeH18.502        Unspecified hereditary corneal dystrophies, left eyeH18.503        Unspecified hereditary corneal dystrophies, bilateralH18.509        Unspecified hereditary corneal dystrophies, unspecified eyeH18.511        Endothelial ...

ICD-10-CM 2021 Codes for your Specialty

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6. Diseases of the nervous system (G00-G99) Code:            Description: G11.10          Early-onset cerebellar ataxia, unspecifiedG11.11          Friedreich ataxiaG11.19          Other early-onset cerebellar ataxiaG40.42          Cyclin-Dependent Kinase-Like 5 Deficiency DisorderG40.833        Dravet syndrome, intractable, ...

ICD-10-CM 2021 Codes for your Specialty

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5. Mental, Behavioral and Neurodevelopmental disorders (F01-F99) Code:          Description:F10.130       Alcohol abuse with withdrawal, uncomplicatedF10.131       Alcohol abuse with withdrawal deliriumF10.132       Alcohol abuse with withdrawal with perceptual disturbanceF10.139       Alcohol abuse with withdrawal, unspecifiedF10.930       Alcohol use, unspecified with withdrawal, ...

ICD-10-CM 2021 Codes for your Specialty

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4. Endocrine, nutritional and metabolic diseases (E00-E89) Code:            Description:E70.81          Aromatic L-amino acid decarboxylase deficiencyE70.89          Other disorders of aromatic amino-acid metabolismE74.810        Glucose transporter protein type 1 deficiencyE74.818        Other disorders of glucose transportE74.819    ...

ICD-10-CM 2021 Codes for your Specialty

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3. Diseases of the blood and blood-forming organs and certain disorders involving the immune mechanism (D50-D89) Code:            Description:D57.03          Hb-SS disease with cerebral vascular involvementD57.09          Hb-SS disease with crisis with other specified complicationD57.213        Sickle-cell/Hb-C disease with ...

Locating Periodontal Disease in ICD-10-CM

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When coding a diagnosis for periodontal disease, keep in mind there are more options than just chronic or acute. To get started, look at chapter 11, Diseases of the digestive system (K00-K95). Looking at this section a little further, you can see this is where the oral cavity is coded ...

CDT and CPT - The Same but Different!

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Reporting a CPT code for an evaluation of a patient is based on time and if the patient is a new or established patient. Evaluation and Management codes are different than other codes, it is important to understand how they are used, prior to 2021 they were based on a ...

IPPS and DRG's: What it Means

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Understanding hospital pricing can get complicated, so we have broken it down according to CMS and the acute Inpatient Prospective Payment System, also known as IPPS. Find-A-Code uses IPPS for inpatient pricing with our MS-DRG grouper. The following information comes from CMS.gov and answers the most common questions regarding DRGs ...

Final Rule on Communications Technology and 2021 Physicians Fee Schedule

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To create a healthcare system that will benefit providers as well as Medicare beneficiaries there have been several new rules issued that begin on or after January 01, 2021. CMS released the final policy and payment provisions on December 01, 2020, which includes the physician fee schedule (PFS) for 2021. ...

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

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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 ...

COVID Vaccine Codes Announced

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On November 10, 2020, the American Medical Association (AMA) announced the addition of two new codes which will be used for the new COVID-19 vaccines along with 4 new administration codes to be used when reporting the administration of these vaccines.

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 ...

Incident To

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Just about any large clinic you visit will have non-physician practitioners, or NPPs. These will include physician assistants, nurse practitioners, and clinical nurses for example. Practices and clinics can bill under the NPPs if they are credentialed with the payer, but the reimbursement is only 85% of the fee schedule. There ...

OIG – Fraud and Abuse Study with COVID-19 Testing

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According to the Office of Inspector General (OIG), “The coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented demand for diagnostic laboratory testing to determine whether an individual has the virus. Beyond the COVID-19 tests, laboratories can also perform add-on tests, for example, to confirm or rule out diagnoses ...

Medicare Improper Payment Report for Chiropractic (2019)

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CMS audits claims on an annual basis to identify improper payments. These improper payments do not measure fraud. Rather, they estimate the share of payments that did not meet Medicare coverage, coding, and billing rules. In the most recent Improper Payment Report by specialty, chiropractic has the highest Part B improper payment ...

Medicare Improper Payment Report for Behavioral Health Services (2019)

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CMS audits claims on an annual basis to identify improper payments. These improper payments do not measure fraud. Rather, they estimate the share of payments that did not meet Medicare coverage, coding, and billing rules. In the most recent Improper Payment Report, behavioral health services have some of the highest Part ...

Medicare Improper Payment Report (2019)

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The Medicare Improper Payment Report for 2019 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from July ...

Stay out of Trouble — Understand the Qualified Medicare Beneficiary (QMB) Program

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To assist low-income Medicare beneficiaries, CMS created the Qualified Medicare Beneficiary (QMB) program; a Medicaid benefit which pays for Medicare deductibles, coinsurance, or copays for any Medicare-covered items and services for Medicare Part A, Part B, and Medicare Advantage (Part C). Providers/suppliers are prohibited from billing premiums and cost sharing to Medicare beneficiaries who are enrolled in QMB.

An Infectious Disease Control Plan is Essential

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Every business encounters infections. The COVID-10 pandemic has only highlighted this fact, but considering that infectious diseases, such as the seasonal flu, are an ongoing problem, all organizations need to implement an Infectious Disease Control Plan as part of an active compliance plan because it’s required by law. Your organization must take steps to mitigate this risk to both patients and employee

New Codes for Cytokine Release Syndrome (CRS)

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New codes for Cytokine Release Syndrome (CRS) are effective October 1, 2020 based on the grade/severity of the symptoms. This article covers the new grading scales.

ICD-10-CM 2021 Coding Updates for Chiropractic

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October 1st is just around the corner and that means it’s time for updates to the ICD-10-CM code set. This year there are some interesting changes such as a new headache type, new codes related to TMJ, several new codes for reporting accidents involving micro-mobility devices (e.g., hoverboard), and some other changes.

Locating a Diagnosis Code in ICD-10-CM for Dental Offices

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Diagnosis codes used to report with procedures are called ICD-10-CM - International Statistical Classification of Diseases. These codes are published annually in October. To find a diagnosis code in ICD-10-CM, it is important to understand how the chapters and sections are set up. Each chapter is broken down into sections and ...

My Location and CBSA is Missing!

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We often get questions on missing Core Based Statistical Areas, known as CBSAs. CBSAs are used for pricing and other factors according to the geographical location. If you do not see your CBSA, it is important to note they are not missing - it may not have an assignment, according to ...

Important Podcast on Dental to Medical Billing

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Be sure and check out this discussion with LaMont Leavitt (CEO of innoviHealth) and Christine Taxin (Adjunct professor at New York University, President of Dental Medical Billing, and Links2Success).  Some of the resources and tools they discuss will help you with your dental coding/billing and education. Do You Have All the Right ...

More COVID-19 Codes Added as of September 8, 2020

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The American Medical Association (AMA) recently announced the addition of two more CPT codes in relation to COVID and the Public Health Emergency (PHE). Codes 99702 and 86413 were posted to the AMA website on Tuesday, September 8, 2020 and new guidelines have been added as well.

Not Following the Rules Costs Chiropractor $5 Million

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Every healthcare office needs to know and understand the rules that apply to billing services and supplies. What lessons can we learn from the mistakes of others? What if we have made the same mistake?

New Value-Based Payment Models for Primary Care (Primary Care First and Direct Contracting)

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This article summarizes the new Medicare value-based payment models: Primary Care First and Direct Contracting.

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

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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.

New and Exciting Changes in the Dental Industry

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My colleagues and I are nerds for information on all things billable—or not billable—in the worlds of dental and medical insurance. One of the most puzzling challenges for me over the past 15 years of teaching has been to understand why we on the dental side are segregated out of ...

Ultrasound - A Complete Exam Must Include the Following

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Real time scanning of the kidneys Abdominal aorta Common iliac artery origins Inferior vena cava Alternaltively, if ultrasonography is being performed to evaluate the urinary tract, examination of the kidneys and urinary bladder constitutes a complete exam. Code 76775 is used when a limited retroperitoneal ultrasound examination is performed. ...

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...

Coding Injections for Pain Management

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Coding for pain management can get confusing. How many injections, the location, and when to use a modifier are all common questions. This article will cover some of the most common injections used in pain management. Trigger Point Injections Trigger point injections are reported by how many muscles are treated using an ...

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...

Impact of 2021 Proposed Medicare Fee Schedule on Chiropractic Offices

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On August 3, 2020, the proposed Medicare Physician Fee Schedule for 2021 was released. This 1,355 page document includes some sweeping changes to the Medicare program. There are a few items in particular which should be noted by chiropractic offices.

Coding with PCS When There is No Code

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ICD-10-PCS covers ALMOST everything! But not quite! What if a body system does not contain a body part for toes or fingers? What about an elbow? When it does not cover what you are looking for, where do you turn?  To the guidelines, of course! There are ICD-10-PCS guidelines just as ...

OIG Report Highlights Need to Understand Guidelines

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A new OIG report once again highlights the necessity for organizations to fully understand requirements for reporting services and having proper documentation. The types of problems addressed in this report are ongoing issues for multiple types of services and specialties and for many different payers.

Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately

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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 ...

New Grouper Added 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 ...

Use the Correct Diagnosis Codes and Revenue Codes to Get Paid for PAD Rehab

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The initial treatment in rehabilitation for patients suffering from Intermittent Claudication (IC) is Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD).  Rehabilitation using SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest.   When reporting 93668 for peripheral arterial disease rehabilitation the following ...

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 ...

New Name Same Great Product! "HCC Plus"

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Payment Adjustment Rules for Multiple Procedures and CCI Edits

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Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...

New ABN Form is Here

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The anticipated changes to the Advanced Beneficiary Notice of Non-coverage (ABN) Form (CMS-R-131) have arrived. This important form is issued to the patient or client by providers, physicians, practitioners, and suppliers in situations where Medicare payment is expected to be denied. You can begin using the new ABN immediately if you so wish. However, it becomes mandatory on August 31, 2020.

Understanding UCR Inpatient Fees used on DRGs

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HCPCS Codes Were NOT all Created for the Same Purpose

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Have you ever wondered why you were unable to find a particular product/code with our DMEPOS search? When looking for HCPCS Level II codes, there are several kinds of codes and not all HCPCS codes were created for the same purpose. If you are searching for a certain HCPCS product ...

Additional COVID-19 Testing Codes Announced

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New coronavirus antigen testing codes announced. These are effective immediately.

CMS- Reminder COVID Assessment and Specimen Collection

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On March 1, 2020, new codes and rules were released to bill for COVID-19 symptom and exposure assessments, as well as specimen collection. CMS has recently sent out reminders on billing for these services, the proper use of the CS modifier on claims, and how they are handling denials due ...

Should I Bill Dental or Medical?

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While you likely find yourself focusing on fewer patients and more on emergency care, it’s a good time to understand how medical billing can allow patients with active infection in the oral cavity to seek the treatment they need.  Forms need to be filled out correctly, and you must carefully follow ...

Outpatient Facility Pricing

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Our newest feature launch offers UCR pricing for Outpatient Facility. We recently released pricing information based on databases of insurance claims from private-sector health care providers.Usual, customary, and reasonable charges (UCR) are medical fees used when there are no contractual pricing agreements and are used by certain healthcare plans and third-party payers to generate ...

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 ...

Proposed Risk Adjustment Changes

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

Watch for Payer Telehealth Coverage Changes

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As our country moves forward with a phased approach to reopening, be sure to pay close attention to individual payer policies regarding how long these changes will remain in effect. Keep in mind that private payer, federal programs (Medicare, Medicaid), and Medicare Advantage plans can all have different timelines as well as different coverage.

Changes in Medicare Advantage and Part D

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The Centers for Medicare & Medicaid Services finalized several changes in Medicare Advantage and Part D on Friday.  The Trump administration has finalized several changes in Medicare Advantage (MA) and Part D in anticipation of bid submissions on June 1. The Centers for Medicare & Medicaid Services (CMS) released  Friday that includes ...

Additional Practice Reopening Tips

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As practices begin reopening across the nation, there are several things that need to be considered. Policies and Procedures Manuals need to be updated, malpractice carriers need to be contacted and everyone needs to consider mental health screenings and support.

Where is the CCI Edit with Modifier 25 on E/M?

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If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.  The use of Modifier 25 is one example ...

Packaging and Units for Billing Drugs

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To determine the dosage, size, doses per package and how many billing units are in each package, refer to the NDC number. Take a look at the following J1071 - Injection, testosterone cypionate, 1mg For example; using NCD # 0009-0085-10 there are 10 doses of 100 mL (100 mg/mL = 1 mL and there are ...

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 ...

Getting Your Practice Back on Track

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As we begin returning back to work, we will all face a new normal. The COVID-19 pandemic has changed the face of business. While it has certainly been a challenge to keep up with the ever-changing regulations (that’s likely to continue for a little longer), exciting new opportunities have also been created, such as the expansion of telemedicine. There’s also the maze of government funding that needs to be navigated and an increased awareness of OSHA standards to implement.

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.

CMS- Change in Funding for COVID-19 Economic Impact

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On Sunday night April 26, 2020, CMS announced they will no longer be "accepting any new applications for the Advance Payment Program, and CMS will be reevaluating all pending and new applications for Accelerated Payments in light of historical direct payments made available through HHS’ Provider Relief Fund." The COVID-19 Pandemic has ...

Effective Risk Adjustment Requires Accurate Calculations

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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.

COVID-19 Clinical Trial Participation Helps Providers Earn MIPS Credit

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All healthcare providers who are currently participating in the MIPS portion of Medicare’s Quality Payment Program may want to participate in the new COVID-19 Clinical Trials improvement activity. Read more about it here.

Special COVID Laboratory Specimen Coding Information

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With all the new laboratory test codes that have been added due to the current public health emergency (PHE), there are a few additional guidelines CMS has released about collecting samples to perform the testing. Please keep in mind that these guidelines are by CMS and may or may not apply to other commercial payer policies.

Emergency Room and Ancillary Services

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Billing for an Emergency department is not the same as billing for a hospital or in the provider's office; there are several differences and requirements. For example. the hospital will report a stay with Diagnosis Related Groups (DRG's), which include hospital resources used during the patient's stay, while office visits ...

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 ...

SOME of Us Non-Essentials May be Able to Get Back on the Road!

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The day is coming when the freeways will have 5:00 pm stop-and-go traffic again, no doubt. However, when it comes to re-opening our world, CMS has Recommendations! Changes are finally here; we are starting to see a decline in COVID-19 cases in some states and certain locations. It may be time ...

Now That is Fraud! Genetic Testing "Public alert"

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Genetic testing is becoming very popular. In fact, so popular you might see it in places you would not expect such as a community event, fairs or any event happening in your community. Some labs may even offer FREE screening for genetic testing. Watch for FREE screening announcements or advertisements ...

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.

New CPT® Codes Approved for COVID-19 Antibody Identification

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On April 10, 2020, the American Medical Association approved and published a revision of code 86318 and added two new codes 86328 and 86769 for reporting Coronavirus [COVID-19] antibody testing.

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.

Medicare Released the Amount they Will pay for COVID Testing Eff 4/14/2020

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ADA is Asking for HELP with Third-Party Payers for Dentists

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With these unprecedented and extraordinary circumstances, dentists are facing new challenges with reimbursement with what is allowed and covered under their contractual obligations with their payers. The ADA recognizes the struggles dental providers are facing and is urging third-party payers to adopt new reimbursement procedures and adjust their fee schedules to help ...

CPT Coding Guidance on New Lab Code for COVID-19

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According to the AMA, "The Addition of one Category I Pathology and Laboratory code (87635) for severe acute respiratory syndrome coronavirus 2 (SARS-2-CoV-2) (Coronavirus disease [COVID-19]) accepted at the March 2020 CPT Editorial Panel meeting. *Note that code 87635 will be a child code under parent code 87471. It is represented here ...

COVID-19 Chiropractic Resources

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COVID-19 Chiropractic Resources contains current, updated information regarding COVID-19. Included are lists of webinars, articles, websites and links pertaining to the ongoing changes.

CMS Important Information on COVID-19 Released

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CMS has recently released some important information on their last MLN, the highlights are below. COVID-19: Dear Clinician Letter CMS posted a letter to clinicians that outlines a summary of actions CMS has taken to ensure clinicians have maximum flexibility to reduce unnecessary barriers to providing patient care during the unprecedented outbreak ...

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.

ICD-10-CM Official Coding and Reporting Guidelines Updated for COVID-19

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The ICD-10-CM Official Coding and Reporting Guidelines have just been updated to include COVID reporting. Additional information beyond the previously released interim guidelines are included. These are the rules that should be followed for claims submission. The notice states that this is for April 1, 2020 through September 30, 2020.

More Telehealth Changes Announced by CMS Chiropractic Offices Should Know About

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On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). The announcement included far more information than is presented in this article which only summarizes the changes to telehealth. In fact, it does change a little of the information included in our March 31st webinar.

More Telehealth Changes Announced by CMS

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On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). See this article for further information as well as references & links to CMS information

CMS-Coverage for Therapeutic Shoes for Individuals with Diabetes

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Therapeutic shoes and inserts can play a vital role in a diabetic patient's health. Medicare may cover one pair every year and three pairs of custom inserts each calendar year if the patient qualifies and everything is handled correctly.  Medicare Benefit Policy Manual explains what is needed for a person with diabetes to ...

Spotlight: UCR Fees are Available on DRGs- Check it Out!

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Check out the information page on any DRG! Look up DRGs by going to the list of DRG codes found under the Codes tab at the top of the page, or simply type in the desired DRG by using the search bar on the homepage. When using the search bar, be sure you have the ...

Providing Telehealth Services During COVID-19 Crisis

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The rules for providing telehealth services during this pandemic have changed and some requirements have been waived. Please keep in mind that “waiving requirements” does not mean that anything goes. Another important consideration is that Medicare and private payers may likely have different rules so you need to make sure that you know individual payer requirements during this time.

Interprofessional Consult Services

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The recent coronavirus crisis has brought non-face-to-face services to the forefront of coding and billing conversations. With the entire healthcare industry focused on caring for patients during an unprecedented and fast-moving pandemic, the goal of increasing patient access while reducing the risk of spreading infection has become paramount. In this climate, ...

2020 Medicare Part D Coverage Gap (AKA donut hole)

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Not every Medicare drug plan has complete coverage for prescription drugs - most have some sort of coverage gap, known as the “Donut Hole”. The coverage gap is a temporary limit on coverage under the drug plan. This coverage gap will not affect everyone and begins after you have used ...

Medicare Part D Coverage Gap (Donut Hole) Closes in 2020

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Overview of the Part D coverage gap, how it got closed, what the picture looks like for 2020, and long-term outlook.

New Biofeedback Codes to replace 90911 Eff 2020-01-01

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CMS announced 90912 and 90913 are to be used starting January 2020 in place of 90911. According to CMS MLN, these new codes, designated as “sometimes therapy”, are reported to furnish these services outside a therapy plan of care when appropriate. Codes are permitted to be used by physicians and Non-Physician Practitioners (NPPs), ...

LATEST COVID-19 INFORMATION FOR BILLING NON-FACE-TO-FACE SERVICES

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Healthcare providers and the population at large are concerned about safe access to care considering the COVID-19 pandemic. As a result, we have received many inquiries this week about how to bill for “telehealth” services. Let’s first address that true telehealth services have some pretty stringent requirements from CMS, including that ...

COVID-19: Cybercrime, Telehealth, and Coding

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Your inbox is probably like mine with all sorts of announcements about COVID-19. Here are just a few reminders of things we felt should be passed along. We have heard of several cases of cybercrime related to this outbreak. For example, there was a coronavirus map which loads malware onto your ...

"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 ...

Implementing Telehealth Visits

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The following is a step-by-step guide on how to convert office-based encounters to telehealth encounters during the current COVID-19 pandemic. These rules may change post-pandemic, as many changes relaxing existing rules were made on a temporary basis by CMS and commercial payers to facilitate patient access and minimize risk of infection. Step ...

Additional Coronavirus Testing Code Announced

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On March 13, 2020, a new CPT code was announced by the American Medical Association (AMA) who maintains the CPT code set. This early release of a CPT code is rare and is effective immediately.

Who Qualifies for Chronic Care Management Services

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Per MLN Chronic Care Management Services, the following patients are eligible: "Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, are eligible for CCM services." Examples of chronic conditions ...

The difference between Jones and Proximal Diaphyseal Fractures of the Fifth Metatarsal (2018-10-23)

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Distinguishing the difference between Jones and Proximal Diaphyseal Fractures of the Fifth Metatarsal can be complicated, here are some examples from PubMed;  A Jones fracture currently is defined as an acute fracture of the fifth metatarsal at the junction between the proximal diaphysis and metaphysis of the fifth metatarsal without distal extension beyond the fourth to fifth intermetatarsal articulation. Tuberosity avulsion fracture (also known as pseudo-Jones fracture or dancer's fracture) A proximal diaphyseal fifth ...

Coronavirus - What in the World is it and How is it Coded? 2020-02-20

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On December 31, 2019, we learned of a deadly outbreak of an unknown virus, with an unknown cause. We have since learned the virus was identified in Wuhan, China as a novel coronavirus (2019-n-CoV). Until we have more information on the 2019-nCoV, persons with an underlying medical condition are considered high ...

Acupuncture Clarification

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In the ChiroCode Newsletter released yesterday regarding Medicare coverage of acupuncture, one sentence in particular has let to some confusion. Read more about it here.

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.

Medicare Begins Covering Acupuncture Services

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Medicare is changing their policy regarding coverage of acupuncture, but in order to provide these services, you must follow their rules.

Q/A: Did Noridian Stop Covering the M99.0- Codes?

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Question: I heard that Medicare Noridian Jurisdiction F (Alaska) has been denying claims with M99.00, M99.01, M99.02, M99.03 etc codes when billed with the CMT CPT codes. Did Medicare change their policy?

Documentation Skills that Increase Your Coding

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Evidence-based medicine such as the updated periodontal staging and caries lesions also gives well-defined information about the clinical condition itself. You cannot just look at the codes, you need to check the policy. When I am coding or teaching coding, you need to use clinical indications when working with documentation ...

A 2020 Radiology Coding Change You Need To Know

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The radiology section of the 2020 CPT© has 1 new, 18 revised, and 14 deleted codes. Interestingly, six of the 14 deleted codes were specific to reporting single-photon computerized tomographic (SPECT) imaging services of the brain, heart, liver, bladder, and others. If your organization reports radiology services, it is...

Documenting telephone calls at your dental practice is just as important as documenting patient visits.

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Documenting telephone calls at your dental practice is just as important as documenting patient visits. Similar to other documentation, the common rule when it comes to call documentation is that if it is not documented, it did not happen. Therefore, every clinically relevant telephone call should be documented. Clinically relevant calls ...

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.

Q/A: How do we Bill Massage Services?

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Question: We are adding a massage therapist soon and have some questions about billing their services.

Billing for Telemedicine in Chiropractic

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Many large private payers recognize the potential cost savings and improved health outcomes that telemedicine can help achieve, therefore they are often willing to cover it. While there are several considerations, there could be certain circumstances where telemedicine might apply to chiropractic care.

Q/A: Can Chiropractors Bill 99211?

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Can chiropractic offices bill code 99211? Technically it can be used by chiropractors, but in most instances, it is discouraged. Considering that 99211 is a low complexity examination for an established patient, this code is not really made for the physician to use. In fact, in 2021, changes are coming for this code...

Non-Surgical Periodontal Treatment

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AAP treatment guidelines stress that periodontal health should be achieved in the least invasive and most cost-effective manner. This is often accomplished through non-surgical periodontal treatment.Non-surgical periodontal treatment does have its limitations. When it does not achieve periodontal health, surgery may be indicated to restore periodontal health.SCALING AND ROOT PLANINGScaling ...

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 ...

CPT 2020 Changes to Psychiatry Services

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As of January 1, 2020, CPT made changes to the health and behavior assessment and intervention codes (96150-96155) and therapeutic interventions that focus on cognitive function (97127). If you code and audit services in this category, you must pay close attention to the changes as they include the removal and ...


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