Medicare Compliance & Reimbursement - 2015 Issue 12
Part B Mythbuster: Are You Making This Medical Decision-Making Mistake?
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Article Overview
This premium article covers a March 31 Part B Ask the Contractor Teleconference from National Government Services and highlights practical Medicare billing topics for Part B practices. It discusses documentation and medical decision-making considerations, use of the X{EPSU} modifier family alongside established modifier guidance, ICD-10 implementation and testing readiness, review-of-systems documentation questions, Medicare rules for face-to-face E/M services, statutorily excluded services, dual-eligible billing concerns, and provider identification issues affecting PQRS reporting. The content is aimed at coders, billers, compliance staff, and practices that submit Medicare claims and want to understand contractor perspectives on common problem areas.
Why This Topic Matters
The article helps readers understand how a Medicare contractor is interpreting several common billing and documentation questions that can affect claim submission, compliance, and reporting accuracy. It is especially relevant for practices trying to reduce denials, avoid improper billing, and prepare for evolving CMS guidance.
Article Sections
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Risk Factors Include Array of Options
Discusses contractor feedback on the broader types of considerations involved in assessing risk within medical decision-making for surgery-related care.
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Where Is National X{EPSU} Guidance?
Summarizes discussion of CMS and contractor communication regarding the X{EPSU} modifier family and its relationship to existing modifier guidance.
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Keep Working toward ICD-10
Covers ICD-10 implementation timing, the status of expected delays, and the availability of testing through Medicare contractors.
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Can ‘Pain Level’ Be Used Twice?
Addresses documentation questions about using patient-reported pain information in more than one section of an encounter record.
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Medicare Requires E/M Face-to-Face
Explains contractor guidance on Medicare billing requirements for office visit services involving counseling when the patient is not present.
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Medicare Won’t Pay Statutorily Excluded Services
Reviews contractor comments on excluded services, dual-eligible billing, deductible considerations, and balance billing limitations.
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Nail Down Billing Provider or Risk PQRS
Addresses provider identification and reporting considerations for therapy services and their impact on quality reporting programs.
What You Will Learn
- How a Medicare contractor frames certain risk factors within medical decision-making
- What the article says about current guidance topics related to X{EPSU} modifiers
- How ICD-10 readiness and testing are discussed in the context of Medicare Part B
- What Medicare billing questions are raised about documentation, patient presence, excluded services, and reporting
- How provider identification can affect claims and quality reporting workflows
Who Should Read This
- Medical coders
- Medical billers
- Compliance staff
- Practice administrators
- Physician group billing teams
- Medicare Part B providers
Codes Discussed
Code Ranges Discussed
Modifiers Discussed
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