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"Quality Payment Program" & "CDT (Dental) Codes" Articles
Click on the title to see the article summary and a link to the full article.
December 8th, 2020
CDT and CPT - The Same but Different!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 8th, 2020
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 ...
November 4th, 2020
Staging and Grading Periodontitis
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 4th, 2020
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 ...
August 7th, 2020
Impact of 2021 Proposed Medicare Fee Schedule on Chiropractic Offices
By Wyn Staheli, Director of Research | Published August 7th, 2020
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.
June 29th, 2020
HCPCS Codes Were NOT all Created for the Same Purpose
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published June 29th, 2020
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 ...
April 22nd, 2020
COVID-19 Clinical Trial Participation Helps Providers Earn MIPS Credit
By Wyn Staheli, Director of Research | Published April 22nd, 2020
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.
January 6th, 2020
CMS Report on QPP Shows Increasing Involvement
By Wyn Staheli, Director of Research | Published January 6th, 2020
MIPS 2018 participation increased according to the final report issued by CMS on January 6, 2020.
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, ...
January 14th, 2019
Q/A: Is G8730 Still Required? Are G Codes Required at all?
By Wyn Staheli, Director of Research | Published January 14th, 2019 - Last Review/Update January 21st, 2019
G8730, when is it required. Many G codes are still active and are required for non-quality reporting.
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 ...
December 20th, 2018
The Diabetic Patient and Medical Manifestations
December 18th, 2018
Quality Measures Finalized for 2019
By Wyn Staheli, Director of Research | Published December 18th, 2018
CMS recently announced that the quality measures for 2019 have been finalized. There are new eligible clinicians so be aware of how that may affect your organization. New ECs are:
Physical therapists
Occupational therapists
Qualified speech-language pathologists
Qualified audiologists
Clinical psychologists
Registered dietitian or nutrition professionals
The following are changes to Electronic Clinical Quality Measures (eCQMs) available ...
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 ...
June 25th, 2018
Small Practices are Affected by MIPS Increased Thresholds
By Wyn Staheli, Director of Research | Published June 25th, 2018
We recently heard about a small practice that had been faithfully submitting all the required “G” codes for the Quality Payment Program (QPP) only to discover that for 2018 they are excluded from MIPS because the low volume threshold increased from $30,000 in Part B allowed charges or 100 Part ...
June 25th, 2018
How Does the Physician Compare Website Affect You?
By Wyn Staheli, Director of Research | Published June 25th, 2018
The physician compare website may not be working quite the way you think it is. Not all providers will have rankings showing up for them. Physician compare lists basic information, but quality measure information was not added until this year (2018) and not all quality measures are included in the ...
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%....
February 1st, 2018
Using a 2015 Certified EHR in MIPS Year 2
By Diana Strubler | Published February 1st, 2018
The following information is from BC Advantage. As of Dec 31, 2017, Acumen EHR v8.0 achieved Office of the National Coordinator for Health Information Technology (ONC-Health IT) 2015 edition certification! What's a 2015 CEHRT?A CEHRT (Certified EHR Technology) is defined by CMS specifically for their incentive payment programs such as...
February 1st, 2018
Reporting Tooth Numbers and Oral Cavity Areas
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 1st, 2018
When billing for dental procedures you need to identify the exact tooth and/or location in the oral cavity. Qualifiers are used to report the location and tooth number. When billing procedures on teeth and the oral cavity, the JP qualifier is used to identify the tooth number(s) and the JO ...
January 16th, 2018
Patient Relationship Codes
By Wyn Staheli, Director of Research | Published January 16th, 2018
Section 1848(r)(4) of MACRA requires that claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, include codes for the following:
care episode groups
patient condition groups
patient relationship categories
Previously, CMS decided to use procedure code modifiers to report patient relationship codes on Medicare ...
January 10th, 2018
New MIPS Reporting Option for 2017 Data
By Wyn Staheli, Director of Research | Published January 10th, 2018
On January 2, 2018, CMS announced a new data submission system for eligible clinicians to report quality measures for the Quality Payment Program. Data may be submitted through the new platform on the qpp.cms.gov website. The announcement stated:
Data can be submitted and updated any time from January 2, 2018 to March ...
January 4th, 2018
CMS Launches Data Submission System for Clinicians in the Quality Payment Program
By Find-A-Code | Published January 4th, 2018
Today, the Centers for Medicare & Medicaid Services (CMS) announced that doctors and other eligible clinicians participating in the Quality Payment Program can begin submitting their 2017 performance data using a new system on the Quality Payment Program website (qpp.cms.gov). The data submission system is an improvement from the former...
January 2nd, 2018
Quality Payment Program in 2018
By Wyn Staheli, Director of Research | Published January 2nd, 2018 - Last Review/Update January 30th, 2019
I checked the government website to see if I am an eligible clinician and it says that I am not. I just don't want to get blindsided with a letter saying I will be penalized. Is there anything you would suggest or recommend that I do now to protect myself from future penalties. Thank you
December 28th, 2017
Moderate Sedation Services - CPT has 6 Codes to One Dental Code
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 28th, 2017
When billing a medical code instead of the dental code D9223 -Deep sedation/general anesthesia - each 15 minute increment, consider the following medical codes: (Be sure to review the AMA guidelines to see if they fit the procedure you are doing). If a dental office is doing conscious sedation for a patient ...
December 13th, 2017
Appropriate Use Criteria for Advanced Diagnostic Imaging Services - 2018 Final Rule
By Jared Staheli | Published December 13th, 2017
What is the AUC program? From the CMS website:
Section 218(b) of the Protecting Access to Medicare Act of 2014 amended Title XVIII of the Social Security Act to add section 1834(q) directing CMS to establish a program to promote the use of appropriate use criteria (AUC) for advanced diagnostic imaging ...
December 11th, 2017
Quality Payment Program Resources
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published December 11th, 2017
CMS posted new Merit-based Incentive Payment System (MIPS) resources on Quality Payment Program Resource Library webpage:
CMS Web Interface: Excel template for uploading sample beneficiary data with corresponding user guide and instructional video
Extreme and Uncontrollable Circumstances Fact Sheet: Overview of the policy established in the interim final rule with comment period to support clinicians affected by the California wildfires and ...
November 30th, 2017
Why You Should Stop Using ROM as an Outcome Measure
By Dr. Ron Feise, Practice Consultant and Coach with RJF Consulting - www.chiroevidence.com | Published November 30th, 2017 - Last Review/Update January 30th, 2019
We received this email from a chiropractic colleague: “I recently attended a
continuing education seminar accredited by a chiropractic college. The presenter
was talking about outcome measures and highly recommended cervical and
lumbar range of motion (ROM) as a good outcome measure for patients with
spinal conditions. But I am hesitant to use ROM, because it seems to be
inconsistent with a patient’s status.”
What does the current research demonstrate?
November 7th, 2017
Four Final Rules Affecting CMS Payments for 2018
By Wyn Staheli, Director of Research | Published November 7th, 2017
It’s a season for changes. CMS just finalized four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018
HHAs: Payment Changes for 2018
Quality Payment Program Rule for Year 2
This ...
November 6th, 2017
New Payment Rulings Could Affect You
By Wyn Staheli, Director of Research | Published November 6th, 2017
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
November 6th, 2017
Payment Rulings and Small Provider Practices
By Wyn Staheli, Director of Research | Published November 6th, 2017
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems:
Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018
Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
November 3rd, 2017
Importance of Outcomes Measurements
By Wyn Staheli, Director of Research | Published November 3rd, 2017
One important component of health care reporting is the utilization of quality measures which are typically classified into one of three broad categories: structure, process, or outcome.
Structural measures define the healthcare provider’s capacity, systems, and processes (e.g., EHR use, ratio of providers to patients)
Process measures indicate what providers do to ...
September 29th, 2017
Does Every Visit Need to Document Quality and Quantity of Pain & Update the Treatment Plan?
By ChiroCode | Published September 29th, 2017 - Last Review/Update February 5th, 2019
Does every single visit need to document quality and quantity of pain and an update to the treatment plan?
September 29th, 2017
Don't do the MIPS Minimum
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published September 29th, 2017 - Last Review/Update March 4th, 2019
Doing the MIPS Minimum - Penny Wise but Pound Foolish?
Are you planning to “do the MIPS minimum” - the “Test” reporting option - in 2017 and submit the minimum amount of data possible to avoid the penalty? Perhaps every silver lining does not have a cloud, but “Pick Your Pace” sure does. Just as we cheered when the SGR was buried, only to see MIPS emerge from the grave, perhaps the “Pick Your Pace” regulations should undergo more scrutiny before we throw our hats into the air at this regulatory “reprieve.”
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.
August 29th, 2017
Quality Measures for Chiropractic - 2017
By Wyn Staheli, Director of Research | Published August 29th, 2017
Performance Measurement Codes for Chiropractic:
Although there are hundreds of Performance Measurement (PM) services and events, only two may be reported for chiropractors for the 2017 reporting year.
Pain Assessment and Follow-Up
131
ENCOUNTER: 90791, 90792, 92002, 92004, 92012, 92014, 92507, 92508, 92526, 96116, 96118, 96150, 96151, 97161, 97162, 97163, 97164, 97165, 97166, 97167, ...
August 24th, 2017
Q/A: MIPS and G Codes
By Brandy Brimhall, CPC CPCO CMCO CPMA QCC | Published August 24th, 2017 - Last Review/Update February 5th, 2019
We have one doctor in our practice who qualifies under the MIPS guidelines so he is continuing to use the PQRS and G-codes. We are having the rest of our doctors do the same, just in case, and because it is good practice, but is that completely unnecessary and can it possibly do us more harm than good?
August 11th, 2017
Do Other States Lower Payments for Crowns by Delta or Blue Cross?
By Christine Taxin | Published August 11th, 2017
Question: A subscribers from the State of Michigan has asked this:
Has anyone from other states seen the fees for crowns lowered by Delta or Blue Cross?
Answer: First look at your contracts, and see if there is anything in it that allows for fees to be lowered. Next, look up your ...
May 5th, 2017
Your MIPS Resources
By Evan Gwilliam, DC, MBA, BS, CPC, CCPC, CPC-I, CPMA, NCICS, MCS-P, QCC, CMHP | Published May 5th, 2017 - Last Review/Update March 5th, 2019
What is MIPS and what now?
March 30th, 2017
Moderate Sedation Services - CPT has 6 Codes to One Dental Code
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 30th, 2017 - Last Review/Update August 1st, 2017
When billing a medical code instead of the dental code D9223 -Deep sedation/general anesthesia - each 15 minute increment, consider the following medical codes: (Be sure to review the AMA guidelines to see if they fit the procedure you are doing). If a dental office is doing conscious sedation for a patient ...
March 13th, 2017
Reporting Unilateral Procedures
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 13th, 2017 - Last Review/Update July 28th, 2017
Some procedures are unilateral such as D7840-Condylectomy. It is important to consult with your payer on reporting requirements. Some payers require two separate line items with a LT or RT HCPCS Modifier, while others require only one modifier to be appended to the claim.
When billing a medical code for a Condylectomy, ...
February 27th, 2017
Opting Out of MIPS & MACRA
By ChiroCode | Published February 27th, 2017 - Last Review/Update February 8th, 2019
Question: Is it true that I can opt out of MIPS & MACRA if my part B charges are less than or equal to $30,000? If so, are the charges based on covered Medicare charges (98940, 98941, 98942) or all charges sent to Medicare? Some patients want non-covered charges sent to Medicare too.
February 6th, 2017
Quality Reporting is not Just for CMS
By Wyn Staheli, Director of Research | Published February 6th, 2017
If you thought that quality reporting is just for CMS, you are wrong. Other payers recognize the need to establish quality metrics.
January 23rd, 2017
Virtual Groups and MIPS
By Wyn Staheli, Director of Research | Published January 23rd, 2017
During the comment period of the MIPS Proposed Rule (Medicare Program; Merit-Based Incentive Payment System (MIPS) and Alternative Payment Model (APM) Incentive Under the Physician Fee Schedule, and Criteria for Physician-Focused Payment Models), there were some concerns about NPI and TIN usage for MIPS reporting for smaller organizations.
The following statements are from the MIPS Final ...
January 16th, 2017
Alternative Payment Models (APMs) and Advanced APMs
By Wyn Staheli, Director of Research | Published January 16th, 2017
When CMS Released the NPRM regarding the Quality Payment Program (QPP), it included two payment tracks: MIPS and Advanced Alternative Payment Models (APMs). Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs. So how do these payment models differ?
According to a fact sheet ...
December 28th, 2016
Medicare’s Quality Payment Program: Getting Paid for Value Instead of Volume
By ChiroCode | Published December 28th, 2016 - Last Review/Update February 8th, 2019
The government has become increasingly concerned with how they spend money in the healthcare sector. As part of the latest proposal to fix this, the Medicare Access and CHIP Reauthorization Act (MACRA) was passed in 2015. This law changes reimbursement to remunerate providers more when they provide high quality care rather than just more care. It rewards value over volume. It also ends the flawed Sustainable Growth Rate (SGR) formula that had been in use to determine Medicare payment for many years. And, it combines three other quality-based programs into one. It’s biggest and lasting impact may be how it influences the way that patients select the provider they choose to see.
December 15th, 2016
CMS Announces Additional Opportunities for Clinicians Under the Quality Payment Program
By Brittney Murdock, QCC, CMCS, CPC | Published December 15th, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced more new opportunities for clinicians to join Advanced Alternative Payment Models (APMs) to improve care and earn additional incentive payments under the Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Beginning in January...
October 27th, 2016
Sedation used on a Dental Patient for a medical procedure
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 27th, 2016 - Last Review/Update August 1st, 2017
When you need to bill a medical code instead of the dental code D9223, consider the following medical codes, and be sure to review the AMA guidelines to see if they fit the procedure you are doing. If a dental office is doing conscious Sedation for over 5 years old there is ...
October 17th, 2016
CMS Finalizes the New Medicare Quality Payment Program
By ChiroCode | Published October 17th, 2016 - Last Review/Update March 5th, 2019
On October 14, HHS finalized its policy implementing the Merit-Based Incentive Payment System (MIPS) and the Advanced Alternative Payment Model (APM) incentive payment provisions in the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), collectively referred to as the Quality Payment Program.
September 27th, 2016
Changes in Dental codes for 2017
By Christine Taxin | Published September 27th, 2016
Below is a list of changes in Dental Codes for 2017, please do not use these codes until January of 2017. Also, understand how to use and remember document, document why you are using any code.DIAGNOSTIC D0120-D0999REVISIONS:NO CHANGESNEW CODE:D0414 Laboratory Processing of microbial specimen to include culture and sensitivity studies, ...
September 9th, 2016
CMS offering options for MACRA Participation. You Choose - Be prepared!
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published September 9th, 2016
The most recent Blog Post from CMS has given a new update on The bipartisan Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). CMS states they will allow providers four options of reporting for the first year of the program stating they can pick their pace of participation for the ...
June 7th, 2016
A dental guide to cross-coding for oral cancer screening
By Christine Taxin | Published June 7th, 2016 - Last Review/Update January 30th, 2017
It is possible to bill medical insurance in the dental office for oral cancer testing. This will show you how
April 13th, 2016
CMS Releases Core Quality Measures for 7 Specialties
By Wyn Staheli, Director of Research | Published April 13th, 2016
On February 16, 2016, CMS, in conjunction with major commercial health plans and physician groups, released the first set of core measures, which will be used as the basis for quality-based payments. Part of the MACRA - SGR repeal was to begin to implement payment systems based on quality measures rather than the previous PPS system. This announcement marks the beginning of this process.
January 29th, 2016
What is MIPS?
By Wyn Staheli, Director of Research | Published January 29th, 2016
The Merit-Based Incentive Payment System (MIPS) combines PQRS, VM, and EHR into a single Medicare pay-for-performance quality payment system scheduled to begin in 2019.
November 10th, 2015
Watch for new CDT codes in 2016
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published November 10th, 2015 - Last Review/Update January 23rd, 2017
New codes revisions and deletions effective January 2016
New CDT Codes and Descriptions
D0251 EXTRA-ORAL POSTERIOR RADIOGRAPHIC IMAGE D0422 COL & PREP GENETIC MATERIAL-LAB & REPORT D0423 GENETIC TEST-SUSCEPTIBILITY TO DISEASE D1354 INTERIM CARIES ARRESTING MEDICAMENT APPL D4283 AUTO CONNECTIVE TISSUE GRAFT/EACH ADD TH D4285 NON-AUTO CONNECTIVE TISSUE GRAFT/ADD TH D5221 MAXILLARY PARTIAL-RESIN BASE D5222 MANDIBULAR PARTIAL-RESIN BASE D5223 MAXILLARY ...
August 19th, 2015
A Dental Guide to Cross-Coding for Oral Cancer Screening
By Christine Taxin Adjunct Professor, University of New York School of Dentistry - Links2Success.biz | Published August 19th, 2015
Dental professionals are a patient’s primary source of screening within the oral cavity; thus attention must be paid to the most common oral malignancy: squamous cell carcinoma. Historically such malignancies were attributed only to patients with a history of extensive alcohol and tobacco use. However, other risk factors such as ...
August 10th, 2015
Orthognathic Surgery - Medical Policy Criteria - Regence
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 10th, 2015
Orthognathic surgery involves the surgical manipulation of the facial skeleton, particularly the maxilla and mandible, to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies, which may be caused by congenital or developmental anomalies or by traumatic injury.
[1] Note: This policy does not address the surgical ...
August 7th, 2015
TMJ Medical Necesity and Documentation- Aetna
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 7th, 2015 - Last Review/Update August 7th, 2017
Notes: Most Aetna HMO plans exclude coverage for treatment of temporomandibular disorders (TMD) and temporomandibular joint (TMJ) dysfunction
For plans that cover treatment of TMD and TMJ dysfunction, requests for TMJ surgery require review by Aetna's Oral and Maxillofacial Surgery patient management unit. Reviews must include submission of a problem-specific history ...
August 7th, 2015
Orthognathic Surgery - Medical Policy Criteria - Regence
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 7th, 2015 - Last Review/Update August 7th, 2017
Orthognathic surgery involves the surgical manipulation of the facial skeleton, particularly the maxilla and mandible, to restore the proper anatomic and functional relationship in patients with dentofacial skeletal anomalies, which may be caused by congenital or developmental anomalies or by traumatic injury.
[1] Note: This policy does not address the surgical ...
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