"Preventive Medicine" & "Payer Guidelines" Articles

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

July 9th, 2020

Payment Adjustment Rules for Multiple Procedures and CCI Edits

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2020

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 ...

May 20th, 2020

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

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 20th, 2020

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 ...

March 21st, 2020

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

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2020

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 ...

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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 ...

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 ...

June 13th, 2019

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

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019

Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...

May 29th, 2019

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

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 29th, 2019 - Last Review/Update June 4th, 2019

Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?

May 13th, 2019

Electrical Stimulation and Electromagnetic Therapy Devices

By Raquel Shumway | Published May 13th, 2019 - Last Review/Update May 20th, 2019

Electrical Stimulation and Electromagnetic Therapy Devices can be used for pain, muscle atrophy, help spinal cord injuries, treat symptoms caused by other medical conditions and can be used in the treatment of wounds. This Regence BC/BS article lists codes and devices and gives guidance on coding from Medicare Advantage viewpoint.

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 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 ...

January 10th, 2019

Are You Protecting Your Dental Practice From Fraud?

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 10th, 2019

With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...

November 1st, 2018

CMS: Medicare Diabetes Prevention Program Expanded Model

By Find-A-Code | Published November 1st, 2018

CMS announces the Medicare Diabetes prevention program is now a new covered service. Per a recent MLN news release. Medicare Beneficiaries will be notified in 2019 in a Medicare handout. Diabetes affects more than 25 percent of Americans aged 65 or older, and its prevalence is projected to increase approximately...

July 17th, 2018

Understanding the Level of Preventative Services (Grades and Suggestions)

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 17th, 2018

It is essential for providers, clinicians, and other users to understand the importance of providing preventative services. The U.S. Preventative Services Task Force (USPSTF) has recommendations and has applied Grade Definitions as a suggested resource to imply the significance and strength of preventative services. The following definitions apply to recommendations ...

June 7th, 2018

New on our TOPICS Page - "Preventive Medicine Coding and Billing Information"

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 7th, 2018

There is a lot of information available for you to utilize on our Topics pages. We have recently added a Preventative Medicine TOPICS page (under subjects), as per customers' request, for searching Preventative Codes. We're made it easy to locate services required under the Affordable Care Act for reporting preventive services. ...

June 4th, 2018

How Many Modalities Are Too Many?

By Dr Evan Gwilliam, Clinical Director for PayDC chiropractic EHR software | Published June 4th, 2018 - Last Review/Update January 30th, 2019

Q: I have a payor who is denying modalities, claiming that they are “excessive”. At a single encounter I billed for: 98940- Chiropractic manipulative treatment (CMT); spinal, 1-2 regions 97110- Therapeutic procedure, 1 or more areas, each 15 minutes; therapeutic exercises to develop strength and endurance, range of motion and flexibility G0283- Electrical stimulation (unattended), to one or more areas for indication(s) other than wound care, as part of a therapy plan of care 97010- Application of a modality to 1 or more areas; hot or cold packs Is this excessive? How do I know how much is too much?

May 22nd, 2018

AMA vs Medicare rules and the use of the PT modifier

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published May 22nd, 2018

Be sure to review the specific payer policy you are submitting claims to. Medicare’s policy requires the use of a different code when a screening colonoscopy becomes a diagnostic procedure requiring you to bill with CPT code 00811 when treating a Medicare Beneficiary. The use of the PT modifier is ...

May 9th, 2018

Preventive Medicine: General Procedures

By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update July 30th, 2018

Preventive Medicine Topics Page General Procedures Procedure Codes 36415: Collection of venous blood by venipuncture 90471: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); 1 vaccine (single or combination vaccine/toxoid) 90472: Immunization administration (includes percutaneous, intradermal, subcutaneous, or intramuscular injections); each additional vaccine (single or combination vaccine/toxoid) (List ...

May 9th, 2018

Preventive Medicine: Links and Resources

By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update July 30th, 2018

Back to Topic Page References Kaiser Permanentehttps://provider.ghc.org/open/coverageAndEligibility/groupHealthPlans/preventive-services-guidelines.pdf Medicare Learning Networkhttps://www.cms.gov/Medicare/Prevention/PrevntionGenInfo/Downloads/MPS-QuickReferenceChart-1TextOnlywithICD9.pdf AAFP - ICD-10 Simplifies Preventive Care Coding, Sort Of - Cindy Hugheshttps://www.aafp.org/fpm/2014/0700/oa1.html List of ACA Preventive Services and CPT Codes - STDshttp://stdtac.org/wp-content/uploads/2014/06/List-of-ACA-Preventative-Services-and-CPT-Codes-_STDTAC.pdf Additional Links and Resources ACA guidelines as per healthcare.govhttps://www.healthcare.gov/coverage/preventive-care-benefits/ Preventive Medicine Listhttps://www1.ghc.org/static/pdf/public/formulary/aca-list.pdf ...

May 9th, 2018

Preventive Medicine: Alcohol Misuse Screening & Counseling

By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update July 30th, 2018

Preventive Medicine Topics Page // Alcohol Misuse Screening and Counseling Procedure Codes G0442: Annual alcohol misuse screening, 15 minutes G0443: Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes 99408: Alcohol and/or substance (other than tobacco) abuse structured screening (eg, AUDIT, DAST), and brief intervention (SBI) services; 15 to ...

May 9th, 2018