2021 CPT E/M Changes
Virtual Conference
Get ahead of the CPT Evaluation and Management changes taking affect in 2021. Master the changes and learn how they will affect your practice.
- 5 Bootcamp sessions and 18 Symposium sessions
- 14 Presenters including CMS and AMA
- On-demand session videos, purchase as bundles or individually
"Diagnosis Coding" & "ICD9v3 Coding" Articles
Click on the title to see the article summary and a link to the full article.
October 12th, 2020
Medicare Improper Payment Report (2019)
By Jared Staheli | Published October 12th, 2020
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 ...
October 1st, 2020
New Codes for Cytokine Release Syndrome (CRS)
By Wyn Staheli, Director of Research | Published October 1st, 2020 - Last Review/Update October 6th, 2020
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.
June 10th, 2020
MEGA - NCCI Edit Changes - WHO Knew?
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 10th, 2020
There was no huge announcement when CMS released new files in April. The files that were released on April 7, 2020, actually replaced files to update the NCCI edits on Procedure to Procedure (PTP) edits and Medically Unlikely Edits (MUE). The updated files included;
291,902 Deleted Procedure to Procedure (PTP) edits
197 Deleted Medically Unlikely ...
March 24th, 2020
"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 24th, 2020
Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...
February 19th, 2020
Q/A: Did Noridian Stop Covering the M99.0- Codes?
By Wyn Staheli, Director of Research | Published February 19th, 2020
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?
January 30th, 2020
Medicare Announces Coverage of Acupuncture Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 30th, 2020
On January 21, 2020, a CMS Newsroom press-release read,
This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for ...
October 7th, 2019
Hypertension & ICD-10
By Raquel Shumway | Published October 7th, 2019
Hypertensive Diseases and ICD-10. Helps and examples for these codes.
October 1st, 2019
The New ICD-10-CM Code Updates Are Here — Are You Ready?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 1st, 2019
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)
A small revision in the description changed[STEC] to (STEC) for B96.21, B96.22, B96.23. Remember, in the instructional guidelines, ( ) parentheses enclose supplementary words not included in the description (or not) and [ ] brackets enclose synonyms, alternative wording, or explanatory phrases.
Chapter 2: ...
September 30th, 2019
Vaccine Administration - When The Right Vaccine Code is Not Enough
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 30th, 2019
Understanding how to apply immunization administration codes properly will support correct reimbursement for vaccinations. Reporting the right vaccine code alone is not enough to guarantee proper billing. The majority of the time, providers can charge for the vaccine/product as well as the administration of the vaccine; always consult your payer ...
September 9th, 2019
Chiropractic 2020 Codes Changes Are Here
By Wyn Staheli, Director of Research | Published September 9th, 2019
There are some interesting coding changes which chiropractic offices will want to know about. Are codes that you are billing changing?
August 13th, 2019
Healthcare Common Procedure Coding System (HCPCS)
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 13th, 2019
There are three main code sets and Healthcare Common Procedure Coding System (HCPCS), is the third most common code set used. They are often called Level II codes and are used to report non-physician products supplies and procedures not found in CPT, such as ambulance services, DME, drugs, orthotics, supplies, ...
July 9th, 2019
The Importance of Medical Necessity
By Marge McQuade, CMSCS, CHCI, CPOM | Published July 9th, 2019
ICD-10-CM codes represent the first line of defense when it comes to medical necessity. Correctly chosen diagnosis codes support the reason for the visit as well as the level of the E/M services provided. The issue of medical necessity is one of definitions and communication. What is obvious to the ...
April 23rd, 2019
What is Medical Necessity and How Does Documentation Support It?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
We recently fielded the question, “What is medical necessity and how do I know if it's been met?"
The AMA defines medical necessity as:
It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
March 27th, 2019
Pain Codes in ICD-10-CM
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 27th, 2019
When coding with ICD-10-CM, pain codes can be found in different sections:
The Body System affected or site-specific pain codes, such as Low Back Pain M54.5, can be found in Chapter 13. Diseases of the Musculoskeletal system (M00-M99). Other examples might be ocular pain H57.1, found in Chapter 7. Diseases of ...
January 23rd, 2019
How to Report Co-Surgeons Using Modifier 62
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2019
Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session.
An easy way to explain this is to visualize a patient requiring cervical fusion where ...
November 8th, 2018
Diagnosis Coding for Cardiology
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 8th, 2018
Diseases of the Circulatory system are found in Chapter 9 and reported with I00 through I99 according to the following sections:
Acute rheumatic fever (I00-I02)Chronic rheumatic heart diseases (I05-I09)Hypertensive diseases (I10-I16)Ischemic heart diseases (I20-I25)Pulmonary heart disease and diseases of pulmonary circulation (I26-I28)Other forms of heart disease (I30-I52)Cerebrovascular diseases (I60-I69)Diseases of arteries, ...
October 19th, 2018
Coding Clinic Officially Defines Spondylolisthesis and Disc Disorder
By Wyn Staheli, Director of Research | Published October 19th, 2018 - Last Review/Update December 19th, 2018
The Coding Clinic for ICD-10-CM and ICD-10-PCS is a quarterly newsletter published by the American Hospital Association's Central Office (AHA). The information they publish is a joint effort of several organizations including the Centers for Disease Control and Prevention (CDC), the National Center for Health Statistics (NCHS), the Centers for Medicare and ...
September 24th, 2018
2019 Code Changes are Just Around the Corner - Are You Ready?
By Wyn Staheli, Director of Research | Published September 24th, 2018 - Last Review/Update January 28th, 2019
The leaves are beginning to change and it’s time once again for the annual code changes for 2019. ICD-10-CM codes are out and will be effective October 1, 2018. CPT code changes also just came out and will be effective January 1, 2019. The ChiroCode DeskBook and ICD-10-CM Coding for Chiropractic books have been ...
July 16th, 2018
CMS Proposed New E/M Codes for Podiatry
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 16th, 2018 - Last Review/Update July 17th, 2018
According to CMS changes are coming for E/M codes. A recent proposal from CMS stated: "The E/M visit code set is outdated and needs to be revised and revalued." Since podiatry tends to furnish a lower level of E/M visits, CMS is proposing new G-codes to report E/M office/outpatient visits. The proposed ...
May 30th, 2018
Coding for Strains in ICD 10
By BC Advantage | Published May 30th, 2018 - Last Review/Update June 4th, 2018
According to the National Institutes of Health, a review was carried out on 20 patients who had a pectoralis major muscle repair between 2003 and 2011, and the results were as follows....
February 1st, 2018
Traumatic Subluxation Coding Controversy
By Wyn Staheli, Director of Research | Published February 1st, 2018
There has been some controversy over the use of the ICD-10-CM subluxation codes commonly referred to as traumatic (S13.1-, S23.1-, and S33.1-). Are they appropriate for chiropractors to use? The answer to that question is complicated. The problem basically lies in the lack of official guidance and differing opinions on ...
January 23rd, 2018
NEW on Find-A-Code...National Coverage Determinations (NCDs)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2018 - Last Review/Update January 25th, 2018
Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...
January 9th, 2018
Billing Electrotherapy with AcuKnee
By Christine Woolstenhulme | Published January 9th, 2018
This code is commonly used to bill for AcuKnee products. Per AcuKnee, “NMES and electrotherapy may be covered by most insurance providers, provided the following criteria are met;”
Documentation of chronic pain or muscle atrophy 3 months or longer
Must document improvement
Must have physician document medical necessity/Prescription
Appropriate authorization from your insurance provider
Suggested codes when billing
64550 initial electrotherapy education and placement
E0720 Electrotherapy unit itself
E0731 Garment ...
January 4th, 2018
Diagnosis Coding with Diagnostic Testing
By Marge McQuade, CMSCS, CHCI, CPOM | Published January 4th, 2018
Adequate documentation is an essential part of selecting a correct code in any setting. When providers order a test, the information that they document regarding the test results determines the primary and secondary diagnosis codes a coder assigns.
If a physician confirms a diagnosis based on the results of a diagnostic ...
November 30th, 2017
Coding Carpal Tunnel Syndrome
By Wyn Staheli, Director of Research | Published November 30th, 2017 - Last Review/Update February 5th, 2019
Q: In order to code carpal tunnel syndrome G56.01 or G56.02, does there need to be documentation that nerve conduction (EMG testing) has been performed to confirm the diagnosis?
October 5th, 2017
Brace Yourself for New ICD-10 and CPT Codes for 2018!
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published October 5th, 2017 - Last Review/Update February 5th, 2019
What is new for Chiropractors for 2018? See for yourself the new ICD-10 and CPT Codes.
September 12th, 2017
ICD-10-CM Coding Advice for Healthcare Encounters in Hurricane Aftermath
By BC Advantage | Published September 12th, 2017 - Last Review/Update January 25th, 2018
This document is intended to be used as a guide to help coding professionals when coding healthcare encounters of those individuals affected by a hurricane.
September 1st, 2017
Medicare Improper Payment Report for Chiropractic (2016)
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 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 ...
September 1st, 2017
Medicare Improper Payment Report for Behavioral Health Services (2016)
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 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 ...
September 1st, 2017
Preventive Services: Hepatitis B Virus (HBV) Vaccine and Administration
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 9th, 2018
The following information from the Medicare Learning Network provides guidance on Hepatitis B Virus (HBV) Vaccine and Administration....
July 14th, 2017
Don’t Overlook Diagnosis Codes During Coding Audits
By Betty Stump, MHA, RHIT, CPC, CCS-P, CPMA, CDIP | Published July 14th, 2017
Coding auditors focus much of their attention exclusively on C.P.T. codes during the review process. After all, codes reported for E and M visits, surgical procedures, and diagnostic services are what generate revenue to the provider or facility. Even more importantly, errors in reporting these services are frequently what give ...
July 13th, 2017
Our Claims are Being Rejected
By ChiroCode | Published July 13th, 2017 - Last Review/Update February 8th, 2019
Question: Our claims are being rejected. We think it is related to our diagnosis codes. What is the reason for this?
June 8th, 2017
Billing Medicare for Certain Replaced Devices
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 8th, 2017 - Last Review/Update July 26th, 2017
When billing for certain replaced devices, Medicare payments should be reduced when a replacement device (cardiac or otherwise) is received by a hospital at a reduced cost (including no cost), or with a credit that is 50 percent or greater than the cost of the device.
Correct billing in such situations ...
May 22nd, 2017
Q/A: What is the ICD-10 Code for Acetabular Labral Tear?
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published May 22nd, 2017 - Last Review/Update February 8th, 2019
What is the ICD-10 code for acetabular labral tear?
February 16th, 2017
Diagnostic Criteria for Behavioral Health
By Wyn Staheli, Director of Research | Published February 16th, 2017
In order to arrive at a diagnosis and check for related complications, a healthcare provider needs to evaluate the patient condition. This may include:
History: This can include the patient's personal history as well as that of the patient's family.
Physical exam: The healthcare provider will try to rule out physical problems ...
February 15th, 2017
Insufficient Documentation
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 15th, 2017 - Last Review/Update August 2nd, 2017
Claims are determined to have insufficient documentation errors when the medical documentation submitted is inadequate to support payment for the services billed - meaning the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary.
Claims are also ...
February 10th, 2017
Q/A: What is the Proper Code for "Lumbar Decompression?
By ChiroCode | Published February 10th, 2017 - Last Review/Update February 8th, 2019
Q: What is the proper code for "Lumbar Decompression?
January 23rd, 2017
Why Should I Document a Differential Diagnosis?
By Evan M. Gwilliam, DC MBA BS CPC CCPC CPC-I QCC MCS-P CPMA CMHP | Published January 23rd, 2017 - Last Review/Update February 8th, 2019
Generating a differential diagnosis — that is, developing a list of the possible conditions that might produce a patient's symptoms and signs — is an important part of clinical reasoning. It allows a provider to perform appropriate testing to rule out possibilities and confirm a final diagnosis.
Courts view the formulation and documentation of a differential diagnosis as evidence of a physician's competence, prudence, and thoughtfulness.
November 29th, 2016
New Mapping Tool - CPT/HCPCS Medicare Denial Rates & Average Charges
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 29th, 2016
Use this tool as a part of an important strategy to improve your processes and stay ahead of denials. Check your most commonly used codes to give your practice a heads up on denial rates and average charges. This is a quick way to view a group of codes or ...
July 13th, 2016
Procedure code set for Procedures ICD-10-PCS to ICD-9-CM
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 13th, 2016
There are some PCS codes that have a GEMS mapping and is available on Find-A-Code, such as ICD-9-CM Vol 3. 02.11, the GEMS mapping can be found in out Map-a-code tool.
See this code mapping to the following PCS codes
CodeDescription00Q20ZZ
Repair Dura Mater, Open Approach
00Q23ZZ
Repair Dura Mater, Percutaneous Approach
00Q24ZZ
Repair Dura Mater, Percutaneous Endoscopic ...
June 28th, 2016
Key Terms in ICD-10
By ChiroCode | Published June 28th, 2016 - Last Review/Update March 5th, 2019
In some places, the ICD-10-CM code set uses words we think we are familiar with. However, a review of the guidelines shows that some of these words have very specific definitions. Here are a few important ones to remember.
March 4th, 2016
Medicare Improper Payment Report for Behavioral Health Services (2014)
By Wyn Staheli, Director of Research | Published March 4th, 2016
Medicare Improper Payment Report information regarding Behavioral Health Services
February 15th, 2016
Q&A: How do You Code for a Bilateral Condition, Such as Sciatica?
By ChiroCode | Published February 15th, 2016 - Last Review/Update March 5th, 2019
How do you code for a bilateral condition, such as sciatica?
February 8th, 2016
How do we Know Which Codes a Payer will Allow?
By ChiroCode | Published February 8th, 2016 - Last Review/Update April 26th, 2019
Question:
How do we know which codes a payer will allow?
January 29th, 2016
American Dental Association releases new guidelines on gum disease treatment
By Christine Taxin | Published January 29th, 2016
The new guidelines recommend using SRP for initial treatment of patients with periodontitis. According to new guidelines from the American Dental Association (ADA), dentists treating patients with chronicperiodontitis, a severe form of gum disease that can lead to tooth loss, are advised to use scaling and root planing(SRP), deep cleaning...
January 8th, 2016
What are External Cause Codes in ICD-10?
By ChiroCode | Published January 8th, 2016 - Last Review/Update September 3rd, 2019
Chapter 20 External Causes of Morbidity includes codes from V00 to Y99. They were greatly expanded in ICD-10-CM.
January 6th, 2016
Coding Excisions and Wound Repairs
By Codapedia | Published January 6th, 2016
Chart audits frequently examine coding associated with lesion removals and wound repairs. In order to assign the appropriate procedure code, certain documentation must be included in the medical record, such as lesion type, excision size, wound repair, and location. Without these important details, providers...
December 21st, 2015
Characteristics of High Risk and How Often Test can be Performed
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 21st, 2015 - Last Review/Update August 7th, 2017
According to Medicares Pub-100, 60 - Colorectal Cancer Screening Ref: AB-03-114;
Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month ...
December 1st, 2015
Burnout and Emergency Medicine
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 1st, 2015
When it comes to Burnout, Emergency Medicine is hit the Hardest according to MedPage Today. The results come from a survey of burnout among U.S. Physicians. The mean average on those reporting burnout was 45.8%. The emergency physicians were certainly reporting higher burnout at more than 60%. There are many factors contributing to the emergency physician’s burnout, such as the intense environment, economic pressures from healthcare, as well as Medicare's quality indicators, which make doctors accountable for things they have no control over.
September 25th, 2015
Bone Mass Measurements (BMMs)
By Find-A-Code | Published September 25th, 2015
Listed is a summary of the revisions and additions to Chapter 13 of the Medicare Claims Processing Manual and Chapter 15 of the Medicare Benefit Policy Manual.
CHAPTER 13
Effective for dates of service on and after January 1, 2007, the CY 2007 Physician Fee Schedule final rule expanded the number of ...
August 20th, 2015
Covered Bariatric Surgery Procedures
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 20th, 2015
Covered Bariatric Surgery Procedures
Effective for services on or after February 21, 2006, Medicare has determined that the following bariatric surgery procedures are reasonable and necessary under certain conditions for the treatment of morbid obesity.
The patient must have a body-mass index (BMI) 35, have at least one co-morbidity related to ...
August 10th, 2015
MSN - Specifications for Section 3: Claims (Rev. 3210, 04-16-15)
By Jared Staheli | Published August 10th, 2015
A. Section Title
POSITION
This subsection contains information of a fixed size. It is fixed in width but may vary in overall length.
The content area begins (0˝, 0.22˝), 7 points from the baseline of the content described above under the Headers for Other Pages subsection. It is full-page or 540 points in ...
August 3rd, 2015
Notice of Election (NOE) - Form CMS - 1450 (Rev. 3118)
By Find-A-Code | Published August 3rd, 2015
When a Medicare beneficiary elects hospice services, hospices must complete form locators identified in section 20.1.2 for the Uniform (Institutional Provider) Bill (Form CMS-1450), which is an election notice.
In addition, the hospice must complete the Form CMS-1450 when the election is for a patient who has changed an election from one ...
August 3rd, 2015
Method for Computing Fee Schedule Amount (Rev. 1, 10-01-03)
By | Published August 3rd, 2015
B3-15006
The CMS continually updates, refines, and alters the methods used in computing the fee schedule amount. For example, input from the American Academy of Ophthalmology has led to alterations in the supplies and equipment used in the computation of the fee schedule for selected procedures. Likewise, new research has changed ...
July 20th, 2015
Payment Jurisdiction Among A/B MACs (B) for Services Paid Under the Physician Fee Schedule and Anesthesia Services (Rev. 3086)
By Find-A-Code | Published July 20th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014) The jurisdiction for processing a request for payment for services paid under the Medicare Physician Fee Schedule (MPFS) and for anesthesia services is ...
July 17th, 2015
Implementation of Payment Policy for Deported Medicare Beneficiaries (Rev. 943, Issued: 05-05-06)
By Find-A-Code | Published July 17th, 2015
A. CWF Editing of Claims
1. An auxiliary file shall be established in the Common Working File to contain deportation status.
2. This auxiliary file will be the basis for an edit that rejects claims submitted by Medicare contractors.
3. The edit will reject a claim where the beneficiary HIC number on ...
July 17th, 2015
Provider Charges to Beneficiaries (Rev. 2921, Issued: 04-04-14)
By Find-A-Code | Published July 17th, 2015
In the agreement/attestation statement signed by a provider, it agrees not to charge Medicare beneficiaries (or any other person acting on a beneficiary’s behalf) for any service for which Medicare beneficiaries are entitled to have payment made on their behalf by the Medicare program. This includes items or services for ...
July 17th, 2015
Reassignments by Nonphysician Suppliers - Claims Submitted to FIs (Rev. 1, 10-01-03)
By Find-A-Code | Published July 17th, 2015
Definition of Participating From MIM 3005
Nonphysician suppliers may reassign benefits under conditions similar to those under which physicians reassign benefits. Note, however, that when a supplier furnishes services to patients of a participating provider (e.g., a participating hospital or SNF) under arrangement (within the meaning of §1861(w) of the ...
July 17th, 2015
Indirect Payment Procedure (IPP) - Payment to Entities that Provide Coverage Complementary to Medicare Part B (Rev. 2896, Issued: 03-07-14)
By Find-A-Code | Published July 17th, 2015
Medicare Part B payment otherwise payable to a beneficiary for the services of a physician or supplier who charges on a fee-for-service basis may be paid to an entity using the indirect payment procedure (IPP). Any entity registered in accordance with the instructions in Pub. 100-08, chapter 15, sections 15.7.9 ...
July 17th, 2015
Payment to Physician or Other Supplier for Diagnostic Tests Subject to the Anti-Markup Payment Limitation - Claims Submitted to A/B MACs (B) (Rev. 3089, Issued: 10-21-14)
By Find-A-Code | Published July 17th, 2015
(Rev. 3089, Issued: 10-21-14, Effective Date: January 1, 2015 - For Analysis, Design, and Programming April 1, 2015 - For Testing and Implementation; ImplementationJanuary 5, 2015, April 6, 2015 – For MAC testing of PECOS changes only)
A physician or other supplier may bill for the technical component (TC) and/or professional ...
July 17th, 2015
Mandatory Assignment on Carrier Claims (Rev. 2487, Issued: 06-08-12)
By Find-A-Code | Published July 17th, 2015
The following practitioners who provide services under the Medicare program are required to accept assignment for all Medicare claims for their services. This means that they must accept the Medicare allowed amount as payment in full for their practitioner services. The beneficiary’s liability is limited to any applicable deductible plus ...
July 17th, 2015
Nature and Effect of Assignment on Carrier Claims (Rev. 643, Issued: 08-12-05)
By Find-A-Code | Published July 17th, 2015
Assignment is a written agreement between beneficiaries, their physicians or other suppliers, and Medicare. The beneficiary agrees to let the physician or other supplier request direct payment from Medicare for covered Part B services, equipment, and supplies by assigning the claim to the physician or supplier. The physician/supplier in return ...
July 10th, 2015
Medicare Carrier or RRB-Named Carrier to Welfare Carrier (Rev. 2474, Issued: 05-18-12)
By Find-A-Code | Published July 10th, 2015
When a Medicare carrier or RRB-named carrier receives a query reply from CMS that includes a disposition code 46 and a welfare administration carrier number, it transfers the claim to the welfare carrier and notifies the beneficiary. Any pertinent information received or developed is transferred with the claim.
This occurs only ...
July 9th, 2015
Exceptions to Jurisdictional Payment (Rev. 1, 10-01-03)
By Find-A-Code | Published July 9th, 2015
Exceptions to billing the area carrier are:
• A claim for covered services performed in the United States by a legally authorized Canadian or Mexican physician is within the jurisdiction of the carrier servicing the location where the services were rendered.
• Because coverage of Part B services furnished in Canada or ...
July 9th, 2015
Suppliers of Durable Medical Equipment, Prosthetics, Orthotics, Supplies, Parental and Enteral Nutrition (PEN) (Rev. 2487)
By Find-A-Code | Published July 9th, 2015
(Issued: 06-08-12, Effective: 01-01-11, Implementation: 06-19-12) B3-3116, B-3102
Claims for DMEPOS submitted by suppliers for durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS) are handled by Durable Medical Equipment Medicare Administrative Contractors (DME MACs).
To determine which services are processed by DME MACs vs. local carriers, CMS maintains and updates a table ...
July 9th, 2015
Railroad Retirement Beneficiary Carrier (Rev. 142, 04-16-04)
By Find-A-Code | Published July 9th, 2015
Carrier jurisdiction claims for individuals who are QRRBs, including those who are entitled to both social security and railroad retirement benefits, are handled by the Palmetto Government Benefits Administrators (GBA) LLC, a subsidiary of Blue Cross and Blue Shield of South Carolina, with the following exceptions:
• The services are furnished ...
July 7th, 2015
Policy for Intensive Behavioral Therapy for Obesity (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
For services furnished on or after November 29, 2011, Medicare will cover Intensive Behavioral Therapy for Obesity. Medicare beneficiaries with obesity (BMI ≥30 kg/m2 ) who are competent and alert at the time that counseling is provided and whose counseling is furnished by a qualified primary care physician or other ...
July 7th, 2015
Claim Adjustment Reason Codes (CARCs), Remittance Advice Remark Codes (RARCs), Group Codes, and Medicare Summary Notice (MSN) Messages for Policy for Intensive Behavioral Therapy (Rev. 3232, 01-05-15)
By Jared Staheli | Published July 7th, 2015
Contractors shall use the appropriate claim adjustment reason codes (CARCs), remittance advice remark codes (RARCs), group codes, or Medicare summary notice (MSN) messages when denying payment for obesity counseling sessions:
• Denying services submitted on a TOB other than 13X and 85X:
CARC 171 – Payment is denied when performed by this ...
July 6th, 2015
Medicare Summary Notices (MSNs) for the IPPE (Rev. 1615, 01-05-09)
By Jared Staheli | Published July 6th, 2015
When denying additional claims for G0344, G0366, G0367 and G0368, contractors shall use MSN 18.22 - This service was denied because Medicare only covers the one-time initial preventive physical exam with an electrocardiogram within the first 6 months that you have Part B coverage, and only if that coverage begins ...
July 6th, 2015
Medicare Summary Notice (MSN) and Claim Adjustment Reason Codes (CARCs) for HIV Screening Tests (Rev. 2199, 07-06-10)
By Jared Staheli | Published July 6th, 2015
a. When denying claims for HIV screening submitted without ICD-9 diagnosis codes V73.89, or V73.89 and V69.8, use the following messages:
MSN 16.10 - Medicare does not pay for this item or service.
“Medicare no paga por este articulo o servicio”
CARC 167- This (these) diagnosis(es) is (are) not covered.
Group Code CO (Contractual ...
July 6th, 2015
Medicare Summary Notices (MSNs), Remittance Advice Remark Codes (RARCs), Claims Adjustment Reason Codes (CARCs), and Group Codes for Counseling to Prevent Tobacco Use (Rev. 2058, 01-03-11)
By Jared Staheli | Published July 6th, 2015
When denying claims for counseling to prevent tobacco use services submitted without diagnosis codes 305.1 or V15.82, contractors shall use the following messages:
MSN 15.4: The information provided does not support the need for this service or item.
MSN Spanish Version: La informaciónproporcionada no confirma la necesidadparaesteservicio o artículo
RARC M64 - Missing/incomplete/invalid ...
July 5th, 2015
MSN Messages for Prostate Cancer Screening Tests and Procedures (Rev. 1, 10-01-03)
By Jared Staheli | Published July 5th, 2015
If a claim for screening prostate specific antigen test or a screening digital rectal examination is being denied because of the age of the beneficiary, FIs use MSN message 18.13:
This service is not covered for patients under 50 years of age.
The Spanish version of this MSN message should read:
Este servicio ...
June 29th, 2015
Claims Processing Instructions for Payment Jurisdiction
By Find-A-Code | Published June 29th, 2015
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014)
A. Instructions for the 4010/4010A1 Version of the ASC X12 837 Professional Electronic Claim (for Claims Processed Before Implementation of Version 5010)
Note that ...
June 17th, 2015
Inexpensive or Other Routinely Purchased DME (Rev. 1, 10-01-03)
By Jared Staheli | Published June 17th, 2015
For this type of equipment, contractors pay for rentals or lump-sum purchases. However, with the exception of TENS (see 30.1.2), the total payment amount may not exceed the actual charge or the fee schedule amount for purchase.
A. Inexpensive DME
This category is defined as equipment whose purchase price does ...
June 15th, 2015
Carrier Jurisdiction of Requests for Payment (Rev. 2487)
By Find-A-Code | Published June 15th, 2015
Carriers have jurisdiction for all claims from the following:
• Physicians;
• Other individual practitioners;
• Groups of physicians or practitioners;
• Labs not part of a hospital;
• Ambulance claims submitted by ambulance companies under their own Medicare number (hospitals may operate ambulances as part of the hospital and bill the intermediary (FI));
• Ambulatory ...
June 9th, 2015
Covered Codes for Bariatric Surgery
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 9th, 2015 - Last Review/Update August 17th, 2017
CMS has determined that the following procedures will be covered for beneficiaries who have a body-mass index (BMI) ≥ 35, have at least one co-morbidity related to obesity, have been previously unsuccessful with medical treatment of obesity, and this medical information must be documented in the patient's medical record.
Submitted claims ...
June 9th, 2015
Covered Codes for Bariatric Surgery
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 9th, 2015 - Last Review/Update August 8th, 2017
CMS has determined that the following procedures will be covered for beneficiaries who have a body-mass index (BMI) ≥ 35, have at least one co-morbidity related to obesity, have been previously unsuccessful with medical treatment of obesity, and this medical information must be documented in the patient's medical record.
Submitted claims ...
April 9th, 2015
G0105 - Colorectal Cancer Screening; Colonoscopy on Individual at High Risk
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 9th, 2015 - Last Review/Update August 8th, 2017
Screening colonoscopies (code G0105) may be paid when performed by a doctor of medicine or osteopathy at a frequency of once every 24 months for beneficiaries at high risk for developing colorectal cancer (i.e., at least 23 months have passed following the month in which the last covered G0105 screening colonoscopy was performed). ...
March 16th, 2015
Plantar Fasciitis: Medical Necessity and Cross Codes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 16th, 2015 - Last Review/Update August 9th, 2017
Prior to treatment you must determine Medical Necessity.
Be sure conservative therapy/treatment was previously done and documented for at least 6 months and proven to be unsuccessful.
NSAIDS - at least 4 weeks ineffective or contraindicated
Physical Therapy such as taping and stretching
Activity modification
Splints used at night for more that 4 weeks
Corticosteroid injection
Arch Supports, ...
March 6th, 2015
Antipsychotic Drug use and Patient Care
By Wyn Staheli, Director of Research | Published March 6th, 2015 - Last Review/Update February 18th, 2016
In an effort to improve quality of care in nursing home, CMS has been reviewing PQRS quality measures and offering provider training through a variety of mediums. Antipsychotic drug use is just one of the measures being reviewed. The MLN Connects Provider eNews for February 12, 2015 included the following notice about ...
February 15th, 2015
CMS Opt-Out Regulations and Guidelines
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 15th, 2015 - Last Review/Update March 1st, 2016
40-Effect of Beneficiary Agreements Not to Use Medicare Coverage
(Rev. 160, Issued: 10-26-12, Effective: 01-28-13, Implementation: 01-28-13)
(Rev. 194, 09-03-14)
Normally physicians and practitioners are required to submit claims on behalf of beneficiaries for all items and services they provide for which Medicare payment may be made under Part B. Also, they are ...
February 13th, 2015
Chiropractic Services - Aetna Clinical Policy Bulletin
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 13th, 2015 - Last Review/Update March 1st, 2016
AETNA
Clinical Policy Bulletin: Chiropractic Services
Number: 0107
http://www.aetna.com/cpb/medical/data/100_199/0107.html
Policy
Note: Some plans have limitations or exclusions applicable to chiropractic care. Please check benefit plan descriptions for details.
Aetna considers chiropractic services medically necessary when all of the following criteria are met:
The member has a neuromusculoskeletal disorder; and
The medical necessity for treatment is clearly documented; and
Improvement is ...
December 4th, 2014
OASIS Data to be Submitted via Assessment Submission and Processing (ASAP) System Effective Jan 1, 2015
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 4th, 2014 - Last Review/Update March 1st, 2016
Effective January 1, 2015, OASIS assessment data will be submitted to CMS via the national OASIS Assessment Submission and Processing (ASAP) system. With the implementation of the OASIS ASAP system, Home Health Agencies will no longer submit OASIS assessment data to CMS via their state databases. To access the ...
October 16th, 2014
The Role of Statistical Analysis in Fighting Fraud
By Jared Staheli | Published October 16th, 2014 - Last Review/Update January 30th, 2017
It is common knowledge that fraud is a large problem for payers, who must spend money paying fraudulent claims as well as on recovery. New developments in statistical analysis helps to combat this.
October 8th, 2014
#2 DRIP Line ICD-10 -CM Did you know... ICD-10-CM/PCS Examples: Structural Differences
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 8th, 2014 - Last Review/Update August 9th, 2017
The examples below show the structural differences between ICD-9-CM and ICD-10-CM/PCS.
ICD-9-CM Diagnoses Codes:
3–5 digits
First digit is alpha (E or V) or numeric
Digits 2–5 are numeric; and Decimal is after third digit
Examples:
496 – Chronic airway obstruction, Not Elsewhere Classified (NEC)
511.9 – Unspecified pleural effusion
V02.61 – Hepatitis B carrier
ICD-10-CM Diagnoses Codes:
3–7 digits
Digit 1 is ...
September 11th, 2013
ICD-10 Coding Possibilities for Chiropractic Physicians
By Evan M Wsilliam, DC, CPC, CCPC, NCICS, CCCPC, CPC-I, MCS-P, CPMA | Published September 11th, 2013 - Last Review/Update January 27th, 2017
Right now, it’s hard to say which ICD-10 codes third-party payers will select as medically necessary, but we can make an educated guess based on information from a few sources. More detail is expected from Medicare before the end of 2013. For doctors of chiropractic (DCs), the natural place to start is with the relatively short list of frequently used ICD-9-CM codes for submitting claims. We’ll investigate a handful of diagnosis codes that Medicare recognizes as medically necessary and explore ICD-10-CM code possibilities.
June 21st, 2010
Medicare Fee Alert-June 21, 2010, by Dr. Ron Short
By | Published June 21st, 2010 - Last Review/Update January 27th, 2017
Congress continues to debate the elimination of the negative update that took effect June 1, 2010. The CMS is hopeful that Congressional action will be taken to avert the negative update.
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