decisionhealth Newsletters, Part B News - 2025 Issue 11 (November)
Hospital, nursing facility prolonged services saw a denial spike in year two
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Article Overview
This article examines year-over-year Medicare claims data for prolonged E/M add-on services in hospital, nursing facility, home or residence, and office or other outpatient settings. It is aimed at coding and billing staff who need to understand utilization trends, denial increases, and general operational issues affecting these services. The discussion includes CMS policy timing, medical review limits, and broad reasons that denials may occur.
Why This Topic Matters
Prolonged service add-on codes can be affected by payer edits, policy changes, and reporting errors, which can directly increase denials and disrupt claims processing. Understanding the scope of the article helps coding teams focus on the settings and service categories most affected by these changes.
What You Will Learn
- Which prolonged E/M add-on service settings are discussed in the claims analysis.
- How utilization and denial trends are presented across two years of Medicare data.
- What broad policy and edit-related factors may affect claim denial patterns.
- Why coding and billing teams may need to review reporting practices for prolonged services.
Who Should Read This
- Medical coders
- Coding auditors
- Billing staff
- Revenue cycle teams
- Physician practice managers
Codes Discussed
Code Ranges Discussed
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