"Diagnosis Coding" & "Reimbursement" Articles

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

February 11th, 2021

2021 Medicare Physician Fee Schedule Updates - Do You Really Need to Worry?

By Jared Staheli | Published February 11th, 2021

February 1st, 2021

New Procedure Codes for the Janssen COVID-19 Vaccine

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

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

January 11th, 2021

Good and Bad News Regarding the 2021 Medicare Physician Fee Schedule

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

When the proposed Medicare Physician Fee Schedule came out last year, it really got everyone worried. In a time where we are all facing issues related to COVID, this seemed like a really big problem. Professional organizations lobbied and everyone tried to stop the proposed changes, and the 10.2% decrease didn’t happen, but other changes will still be taking place. So how bad is it really and how will it affect your organization?

December 8th, 2020

IPPS and DRG's: What it Means

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 8th, 2020

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 ...

November 18th, 2020

Cross-A-Code Instructions in Find-A-Code

By Raquel Shumway | Published November 18th, 2020

Cross-A-Code is a tool found in Find-A-Code which helps you to locate codes in other code sets that help you when submitting a claim.

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 15th, 2020

Outpatient Facility Pricing

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 15th, 2020

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 ...

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 ...

April 15th, 2020

New CPT® Codes Approved for COVID-19 Antibody Identification

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

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.

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?

older articles ↓

October 21st, 2019

VA- Reasonable Charges Rules, Notices, & Federal Register

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

October 7th, 2019

Hypertension & ICD-10

By Raquel Shumway | Published October 7th, 2019

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

October 1st, 2019

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 20th, 2019

Are You Aware of Medicare Advantage Plans Timely Filing Rules?

By Aimee Wilcox | Published August 20th, 2019

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

August 13th, 2019

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 ...

April 1st, 2019

Q/A: I Submitted a Claim to the VA and it’s Being Denied. Why?

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

I submitted a claim to the VA and it’s being denied. Why? There are several reasons why your claim might be denied by the Veterans Administration (VA). However, without more information about the claim itself (e.g., services billed), we can only provide the following general information about the VA and chiropractic ...

March 27th, 2019

Pain Codes in ICD-10-CM

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

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

March 1st, 2019

Understanding NCCI Edits

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

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

February 14th, 2019

Proposed Rule: Expanded Telemedicine Benefits for Medicare Advantage Beneficiaries

By Aimee Wilcox | Published February 14th, 2019

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

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, ...

November 7th, 2018

Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?

By Wyn Staheli, Director of Research | Published November 7th, 2018

The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...

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 ...

August 20th, 2018

PSAVE Pilot Program - What Does it Mean to You?

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

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

July 18th, 2018

Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?

By | Published July 18th, 2018

Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed. For ...

June 26th, 2018

WHO Said ICD-11 is Coming Soon

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 26th, 2018

Sooner or later ICD-11 will be released, and it sounds like it will be sooner than later. WHO released the news on June 18, 2018. The World Health Organization stated “ICD-11 will be presented at the World Health Assembly in May 2019 for adoption by Member States, and will come ...

June 15th, 2018

The Money in MIPS

By Diana Strubler | Published June 15th, 2018 - Last Review/Update July 3rd, 2018

Seema Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS), recently announced that 91% participated in the first year of the Quality Payment Program (QPP), barely squeaking by their goal of 90%....

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

Don’t Be Hesitant About Collecting Co-Pays

By | Published February 1st, 2018

If you are hesitant about collecting co-pays, consider that you may be paying interest on credit cards, property mortgages, and business loans. Each dollar that you do not collect in co-pays could have been used to pay down the practice debt. Without question, if you are having difficulty finding ways ...

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

Reimbursement for Therapy Students

By Find-A-Code | Published January 4th, 2018

According to CGS Administrators, qualified professionals may serve as clinical instructors for therapy students within their scope of practice. Physical therapist assistants and occupational therapy assistants may only serve as clinical instructors for physical therapist assistant students and occupational therapy assistant students, respectively, when performed under the direction and supervision ...

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?

November 22nd, 2017

Understanding ASC Pricing

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 22nd, 2017

ASCs (Ambulatory Surgical Centers) have a separate fee schedule with a base allowed amount that is adjusted for each state using Core Based Statistical Areas (CBSA). Under the ASC payment system, Medicare pays facilities for specific ASC covered surgical procedures, however, there are only certain types of procedures that are eligible for payment ...

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 25th, 2017

Last Chance to Start Reporting MIPS

By ChiroCode | Published September 25th, 2017 - Last Review/Update February 5th, 2019

MIPS is a program that allows Medicare to collect data from providers about high quality low cost care that uses technology effectively. There are four categories and providers need to learn about the available measures so that they can pick the ones that make them look the best.

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.

August 4th, 2017

Veterans Choice Program

By Wyn Staheli | Published August 4th, 2017

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

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?

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?

May 2nd, 2017

Plain Film Xray Penalty 2017

By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published May 2nd, 2017 - Last Review/Update January 31st, 2019

Watch Another quick tip from the ChiroCode HelpDesk - Plain Film Xray Penalty 2017. Even though this news comes from Medicare, who does not reimburse chiropractic physicians for x-rays, private payers nearly always follow their example. This represents the trend of X-ray reimbursement for all of healthcare.

February 21st, 2017

Telehealth Psychiatric Service

By Wyn Staheli, Director of Research | Published February 21st, 2017

Telehealth (also known as telemedicine) is playing an ever increasing roll in the reimbursement process. Internet services continue to expand and many insurance payers/providers are now covering (paying for) telehealth services. Telepsychiatry (providing behavioral health services in a telehealth environment) has been highly successful because video conferencing makes providing psych ...

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 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?

February 6th, 2017

Q/A: Would Leaving Box 14 on the 1500 Claim Form Blank Cause Denials?

By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published February 6th, 2017 - Last Review/Update February 8th, 2019

We have been leaving box 14 on the 1500 claim form blank for Medicare claims and are getting denials. Could this be why?

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.

January 13th, 2017

Whiplash Damages

By ChiroCode | Published January 13th, 2017 - Last Review/Update January 31st, 2019

Whiplash Damages in Rear-end Collisions - The Patient’s Dilemma: The rear-end collision is a major cause of cervical spine injuries which often require treatment by chiropractors and other health care practitioners. Claims adjusters trivialize soft tissue injuries [it’s “only” a sprain or strain] but whiplash is real and so are the damages that come with it.

December 7th, 2016

Insurance Denying Everything as Maintenance

By ChiroCode | Published December 7th, 2016 - Last Review/Update March 4th, 2019

Are you having a difficult time getting reimbursed? Are claims being denied because the insurance classifies everything as maintenance?

September 17th, 2016

Consumer Directed Health Plans (CDHP)

By Wyn Staheli, Director of Research | Published September 17th, 2016

Consumer Directed Healthcare Plans (CDHP) were developed as a way to shift the control of healthcare dollars from the insurance companies to the patient (consumer). The goal of these types of plans is to allow the patient to take a more active role in their own health and healthcare decisions ...

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.

June 27th, 2016

CMS Announces Proposed Payment Changes for Medicare Home Health Agencies for 2017 (CMS-1648-P)

By Brittney Murdock, QCC, CMCS, CPC | Published June 27th, 2016

Today, the Centers for Medicare & Medicaid Services (CMS) announced proposed changes to the Medicare home health prospective payment system (HH PPS) for calendar year (CY) 2017 that would foster greater efficiency, flexibility, payment accuracy, and improved quality. Approximately 3.4 million beneficiaries received home health services from approximately 11,400 home ...

June 15th, 2016

Q&A: Do you think insurances will continue to raise deductibles and copay/co-insurance amounts?

By | Published June 15th, 2016 - Last Review/Update March 5th, 2019

Q&A: Do you think insurances will continue to raise deductibles and copay/co-insurance amounts?

May 26th, 2016

Groupon: Is it worth the risk?

By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published May 26th, 2016 - Last Review/Update March 5th, 2019

Our team is frequently asked if it is legal for chiropractic offices to offer coupons or Groupons. We’re not allowed, as a profession, to dramatically discount our services, offer free treatments, or provide gifts or free meals for potential patients. Any one of these things can be considered an “inducement.” Practices that improperly induce patients to seek care or services, for example, by providing coupons for care or supplies, may find that they are in violation of the law if they aren’t careful. So what will that mean to you and your practice? It isn’t pretty.

May 3rd, 2016

Using the SBIRT

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

Screening, Brief Intervention, and Referral to Treatment (SBIRT) services are an effective tool for healthcare providers to identify, reduce, and prevent problematic substance use disorders. Healthcare practices can help their patients and improve their integrated care standards with the proper use of the SBIRT.

May 3rd, 2016

CMS Finalizes its Quality Measure Development Plan

By Kate Goodrich, M.D., M.H.S., Director, Center for Clinical Standards & Quality, CMS | Published May 3rd, 2016

On December 18, 2015, we posted our draft Quality Measure Development Plan, a strategic framework for clinician quality measurement development to support the new Merit-based Incentive Payment System (MIPS) and advanced alternative payment models (APMs). Through March 1, 2016, we asked for stakeholder feedback and received responses from 60 individuals ...

May 3rd, 2016

Provider/Patient Dynamic Changes as Result of High Deductible Plans

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

High-deductible plans are changing the way patients utilize medical services, therefore, providers must also adapt by adjusting both their communication and billing practices to keep pace with these changes.

March 28th, 2016

Are you ready for the value based payment model?

By Codapedia Editor | Published March 28th, 2016

By: Victoria (Tue, Mar/15/2016) Healthcare professionals are being forced to move out of their comfort zones. Sweeping changes are being made to change the way healthcare is provided and paid for. 40% of in-network payments are tied to value. And the traditional fee for service model is expected to disappear over the ...

March 4th, 2016

What is an 'Other Qualified Healthcare Professional'?

By Wyn Staheli | Published March 4th, 2016

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

February 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 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.

December 11th, 2015

The Benefit of Checking Benefits

By | Published December 11th, 2015

Many of your physicians perform surgeries and diagnostic procedures on patients. It is easy to call and determine if precertification is required, but how many of you actually look at what is required of a patient prior to performing the procedure? In many cases outpatient procedures...

August 10th, 2015

Refund Demands and Contracts

By ChiroCode | Published August 10th, 2015 - Last Review/Update January 27th, 2017

Refund demands from payers are not all alike; some could be justified. Recently a payer asked for a refund request from a ChiroCode subscriber. She said: "We sent the No Refund letter from ChiroCode. However, they ignored it and they still want a refund. What do I do next?" Demands for a refund from ...

July 17th, 2015

Exceptions to Assignment of Provider’s Right to Payment – Claims Submitted to A/B MACs (Rev. 1931, Issued: 03-12-10)

By Find-A-Code | Published July 17th, 2015

A. Payment to Government Agency Medicare payment for the services of a provider is not made to a governmental agency or entity except when payment to the governmental agency or entity is permissible under the other listed reassignment exceptions, e.g., where the agency is the employer of the physician. B. Payment ...

June 25th, 2015

Carrier/AB MAC Indicators for the Common Working File (CWF) (Rev. 1586, 10-06-08)

By Jared Staheli | Published June 25th, 2015

The carrier/AB MAC record submitted to CWF must contain the following indicators: Description Payment Indicator Payment Deductible Indicator Deductible Type of Service Pneumococcal “1” 100 percent “1” Zero deductible “V” Influenza “1” 100 percent “1” Zero deductible “V” Hepatitis B “0” 80 percent “0” Deductible applies "1" A payment indicator of “1” represents 100 percent payment. A deductible indicator of “1” represents a zero deductible. A payment indicator of “0” represents 80 percent payment. A ...

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 ...

April 23rd, 2015

Alcohol Screening to Reduce Misuse

By Wyn Staheli, Director of Research | Published April 23rd, 2015 - Last Review/Update June 9th, 2016

April is Alcohol Awareness Month and April 9 is National Alcohol Screening Day. Because alcohol misuse contributes to a variety of both social and medical problems, this day was set aside as a way to reach out, educate and increase awareness in communities. By screenings and other initiatives, at-risk individuals ...

February 25th, 2015

Aetna Policy on Bathroom and Toilet Equipment and Supplies - Coverage

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 25th, 2015 - Last Review/Update February 18th, 2016

Clinical Policy Bulletin:Bathroom and Toilet Equipment and Supplies Number: 0429 Policy Aetna's HMO-based and health network plans (HMO, QPOS, Health Network Only, Health Network Option, Golden Medicare, and U.S. Access) generally follow Medicare's criteria for durable medical equipment (DME) items that are used in the bathroom. Most DME items used in the bathroom are ...

February 4th, 2015

Virtual Cards

By Wyn Staheli | Published February 4th, 2015 - Last Review/Update June 9th, 2016

Sometimes called "disposable," "temporary," or "one-time use" numbers, a virtual credit card number is "like putting a wall" between your transaction and your regular account, says Steve Kenneally, vice president of the American Bankers Association. Although these cards can protect the cardholder from fraud, the use of virtual cards as ...

October 20th, 2014

Least Expensive Alternative Treatment Clause

By Christine Taxin | Published October 20th, 2014 - Last Review/Update January 27th, 2017

Least Expensive Alternative Treatment Clause What your patients do not know! When alternate benefit or LEAT provisions are applied, they are not meant to dictate treatment, question professional judgment or interfere with doctor-patient relationships. The ultimate decision on treatment is up to the dentist and patient. The LEAT provision actually funds a ...

October 16th, 2014

Incarcerated Beneficiary Update - CMS

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 16th, 2014 - Last Review/Update January 30th, 2017

In 2013, CMS initiated recoveries from providers and suppliers based on data that indicated a beneficiary was incarcerated on the date of service. CMS subsequently discovered that some of the data used was incomplete. Since some of these recoveries might have been erroneous, CMS initiated refunds. Most of the incarcerated beneficiary erroneous ...

October 9th, 2014

To Participate or Not to Participate, That is The Question.

By Christine Taxin | Published October 9th, 2014 - Last Review/Update January 27th, 2017

Insurance! Can it be profitable or a big loser? Participating with insurance can initially bring down your revenue as you cut your fees per procedure. It is important to remember that your overhead will not decrease along with the fees. The question is can you make up the revenue by increasing ...

September 25th, 2014

Virtual Credit Cards -A new trend in trying to keep up with E-Health

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017

Beware of the changes sneaking in as “money streams” in the name of EFT standards. Virtual Credit Cards are being used in provider’s offices as payments from payers; clearinghouses are starting to offer this service as well. Effective January 1, 2014, health plans were required to offer electronic funds transfer (EFT). ...

August 27th, 2014

PQRS FAQS

By | Published August 27th, 2014 - Last Review/Update January 30th, 2017

PQRS FAQs: How do I report for the 2014 PQRS? What is the MAV and when does it apply? What happens if we report less than 9 measures across 3 domains? How does CMS apply the MAV Clinical Relation/Domain test for PQRS?

August 26th, 2014

Un-Timely Filing - ZERO Reimbursement

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 26th, 2014 - Last Review/Update January 25th, 2017

Be sure you have office procedures in place to keep an eye on the time frame of your claims: Claims denied by Medicare for “untimely submission” are not eligible for appeal. In fact most carriers do not afford you an appeal if timely filing is an issue; there are only ...

August 12th, 2014

Un-Timely Filing - ZERO Reimbursement

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 12th, 2014 - Last Review/Update January 25th, 2017

I like to call this a FREE clinic visit; it is a pet peeve of mine to see an office lose money due to timely filing. There is no reason for this type of loss; however it is more and more common. First of all Insurance companies are shortening the time ...

April 17th, 2014

EFT Standardization Looks Promising

By | Published April 17th, 2014 - Last Review/Update January 25th, 2017

January 1, 2014 was the required date for adoption of standards for both Electronic Funds Transfer (EFT) and Electronic Remittance Advice (ERA). The Centers for Medicare & Medicaid Services (CMS) recently announced that the implementation of these new standards has resulted in benefits for both providers and CMS. Not surprisingly, ...

March 2nd, 2014

Will mandatory Medicare payment cuts (due to the SGR) get repealed?

By | Published March 2nd, 2014 - Last Review/Update January 27th, 2017

Since 2003, healthcare providers have been dealing with the the short term patches to the Medicare payment system. After all this time, it now appears that Congress is making a move to address the ongoing issues with the Sustainable Growth Rate (SGR). This is the formula that has caused the payment problems with Medicare. Many professional organizations are endorsing the SGR Repeal and Medicare Provider Payment Modernization Act of 2014 (H.R. 4015, S. 2000) and encouraging providers to contact their congressional leaders and lend their support for this legislation. If you wish to join those lending their support CLICK HERE for a helpful tool to contact YOUR congressional leaders. Read More

August 30th, 2012

Inappropriate Medicare Payments for Chiropractic Services

By | Published August 30th, 2012 - Last Review/Update January 27th, 2017

OIG released two reports critical of the way chiropractic handled documentation and coding. Their findings are included in this article. Read further to see what documentation is needed for proper payment.

As required by the Social Security Act, Medicare pays only for reasonable and necessary chiropractic services, which are limited to active/corrective manual manipulations of the spine to correct subluxations. A chiropractic service must have a direct therapeutic relationship to the patient’s condition and provide reasonable expectation of recovery or improvement of function.

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