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November 17th, 2021
Delving Into the 360 Assessment Fraud Complaint
Published November 17th, 2021|
The Department of Justice is pursuing claims of healthcare fraud against Cigna Health-Spring Medicare Advantage plan based on how they used data from their 360 Program in 2012. A review of the allegations may help other payers avoid similar accusations.
November 16th, 2021
Lessons Learned from an RADV Audit Report
Published November 16th, 2021|
If given an opportunity to know ahead of time the questions that would be asked of you in an upcoming interview or quiz, it is likely the outcome would be significantly better than if you were surprised by the questions. This same concept may be applied to audits of risk ...
October 28th, 2021
Understanding ASCs and APCs: Indicators and Place of Service
Published October 28th, 2021|
The decision regarding the most appropriate care setting for a given surgical procedure is determined by the physician based on the patient's individual clinical needs and preferences. Of course, there is a difference in reimbursement, and the billing depends on where the procedure took place, such as an office setting, inpatient ...
October 15th, 2021
Is Your Organization Ready to Deal with Provider Relief Fund (PRF) Audit Contractors?
Published October 15th, 2021 - Last Review/Update October 19th, 2021|
Audits are currently underway to verify the monies distributed through the CARES Act were warranted and properly used by those organizations that received them. The federal government has contracted with financial institutions such as KPMG and PricewaterhouseCoopers, among others, to perform these audits referred to as Provider Relief Fund (PRF) audit contractors, funded with monies from the very same program. There were four phases of funding disbursements with phase 1 audits beginning in September. How ready are you to be audited?
October 14th, 2021
Five Major ICD-10-CM Changes That Can Effect Your Organization
Published October 14th, 2021|
Have you had a chance to review the new ICD-10-CM codes for FY 2022? Did you know that many payers do not want to see unspecified codes when there is a possibility for better data? How adept are you at assigning and sequencing COVID-19 codes? Take a minute to review 5 of the major changes to the FY2022 ICD-10-CM code updates and claim your chance to watch our most recent webinar where we review the newest code updates.
October 6th, 2021
ICD-10-CM Cracks Down on the Use of "Unspecified" in the 2021 Official Guidelines
Published October 6th, 2021|
We always knew there would come a day when payers would look down on an "unspecified" diagnosis code and possibly even deny it or delay payment until a review of the record could be performed. ICD-10-CM was adopted by the U.S. for data analytics, which cannot be accurate if unspecified codes are reported when the documentation verifies greater specificity. Join us for a look at the many guideline changes to ICD-10-CM, a review of the newest code changes and suggestions on documentation improvement to elevate coding protocols.
September 30th, 2021
How Well Will Your Organization Score in the 2022 Star Rating Measures?
Published September 30th, 2021|
How ready is your organization for implementation of the 2022 new Star Rating measures? Creating opportunities for staff to share innovative ideas is essential to creating a successful outcome, so take a minute to review the Part C and D measures today.
September 30th, 2021
Is Coding Based on Addendums or Late Entries Putting You At Risk of Audit Failure?
Published September 30th, 2021|
Independent Health, another Medicare Advantage Organization, has been named in a qui tam (whistleblower) lawsuit and enjoined by the DOJ for allegations of fraudulently upcoding to increase beneficiary risk adjustment scores to obtain higher reimbursement. It appears they used DxID, LLC, a coding consulting subsidiary of Independent Health to retrospectively identify and have providers addend unsupported diagnoses. How is your organization actively protecting against accusations of upcoding by improper use and reporting of diagnoses from provider addenda?
August 16th, 2021
Medicare Advantage - The Fastest Growing Government-Funded Program Undergoing Multiple Fraud Investigations
Published August 16th, 2021|
Medicare Advantage is the fastest growing form of government-funded healthcare and the rate of fraud within this segment has come under increased scrutiny. Funding is determined by the health status of each beneficiary; therefore, accurate coding based on detailed documentation makes the medical record vital to the process because some ...
August 2nd, 2021
Will CMS Allow Medicare Advantage Organizations to Risk Adjust from Audio-Only Encounters?
Published August 2nd, 2021|
While audio-only telehealth services became a covered benefit during the PHE, CMS put limitations on using the data from those encounters for risk adjustment scoring. Medicare Advantage (MA) plans cannot use the information from these encounters to be scored for risk adjustment; however, it can be used for risk adjustment scoring of ACA plans.
July 15th, 2021
How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?
Published July 15th, 2021|
CMS recently announced the 53 Direct Contracting Entities (DCEs) that will be participating in the April 1, 2021 through December 31, 2021 Global and Professional Direct Contracting (GPDC) Model. Among those participating is Clover Health Partners, who runs an in-home primary care program that has the potential to help Medicare ...
June 1st, 2021
Managed Care Organizations Use CMS Tools to Identify Outliers
Published June 1st, 2021 - Last Review/Update June 2nd, 2021|
Managed Care Organizations (MCOs) include risk-adjusted plans whose funding is based on the health status of their beneficiaries. Government-funded MCOs use CMS information to search for suspected cases of fraud and abuse.
May 18th, 2021
OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment
Published May 18th, 2021|
As the OIG has published their intent to further investigate the 9.5% of improper payments based on incorrect ICD-10-CM code assignation, they implore Managed Care Organizations (MCOs) to begin employing some of the CMS tools and data analytic programs used to help identify outliers.
May 6th, 2021
Identifying Risk-Adjusted Services During the Opioid Crisis
Published May 6th, 2021|
Between June 2019 and June 2020, the United States saw a total of 107,750 deaths from COVID-19. The spread of this virus was so extraordinary that it led President Trump to declare a public health emergency, and we watched as individual states began implementing laws and regulations to limit social interaction ...
April 19th, 2021
Q/A: For E/M, How do I Count Tests Ordered in One Department and Performed in Another?
Published April 19th, 2021|
Question: I am in an ENT office as part of a large clinic with separate practices including audiology, CT, and allergy, all billing under the same TAX ID. Sometimes tests are ordered which are done in other departments that my office does not bill for, would those be considered an outside source? Answer: This is a great question and one that has been asked by many coders and auditors.
April 12th, 2021
How to Combat COVID-Related Risk Adjustment Losses with the Medicare Annual Wellness Exam
Published April 12th, 2021|
Identifying new ways to encourage Medicare beneficiaries to schedule and attend their Annual Wellness Exam (AWE) can be difficult, but the Open Enrollment period is a prime time for every payer to identify new beneficiaries and provide a reminder to both new and existing patients that this preventive service does ...
March 18th, 2021
How Reporting E/M Based on Time May Lose Money
Published March 18th, 2021|
Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...
March 10th, 2021
How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment
Published March 10th, 2021|
The role of SDOH in overall patient care and outcomes has become a more common topic of discussion among healthcare providers, payers, and policymakers alike. All are attempting to identify and collect SDOH and correlate the data to patient management which is increasingly seen as necessary to address certain health disparities and identify exactly how SDOH affects patient health outcomes. Learn how to address this important subject.
January 21st, 2021
Looking Beyond an Employee's Coding Credentials
Published January 21st, 2021|
In today's ever-changing healthcare environment, it is important that organizations hire coding and reimbursement personnel who enjoy learning. Each year changes are made in how healthcare services are coded and reported from federal and state laws, the code sets themselves, and varying payer policies. During the public health emergency (PHE) ...
January 7th, 2021
CMS Reduces the Exchange User Fee to Support Lower Premiums for the Consumer
Published January 7th, 2021|
It has been no secret that Americans have been complaining about the high cost of health plans since implementation of the Affordable Care Act (ACA). Premiums and deductibles have skyrocketed and in many states are equal to or exceed the cost of their rent or mortgage payments. As such, most ...
November 24th, 2020
How Might the New 2021 E/M Guideline Changes Impact Risk Adjustment?
Published November 24th, 2020|
While provider organizations are busy learning the new E/M guideline changes being implemented January 1, 2021, Medicare Advantage Organizations (MAOs) are contemplating how the documentation changes for these services may impact risk adjustment coding. To be clear, the new E/M guidelines only pertain to Office and Other Outpatient E/M Services ...
November 5th, 2020
Are You Aware of the 2021 Star Rating System Updates?
Published November 5th, 2020|
Each year the Centers for Medicare & Medicaid Services (CMS) publishes the Star Ratings System Updates for Medicare Advantage (Part C) and Medicare Prescription (Part D). This rating system was developed to help beneficiaries identify and select the health plans that best meet their needs, specifically addressing main issues: Quality of ...
October 12th, 2020
What is the Difference Between the Medicare 1995 and 1997 Documentation Guidelines for E/M Services?
Published October 12th, 2020|
When Medicare determined that providers could follow EITHER the 1995 OR the 1997 Documentation Guidelines for Evaluation and Management Services to determine which level of E/M service to report, because CMS had not clarified that portions of the 1995 and 1997 guidelines could be used together to determine the level of ...
August 24th, 2020
2021 Brings Another Risk Adjustment Calculation Change
Published August 24th, 2020|
In 2021, a big change in Risk Adjustment score calculations will take place, which will affect payments to Medicare Advantage (MA) plans for the coming year and take us closer to quality and value-based programs instead of fee-for-service (FFS) or risk-adjusted (RA). Currently, CMS pays a per-enrollee capitated...
May 13th, 2020
Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?
Published May 13th, 2020|
On April 10th, CMS released a memo with the subject line, “Applicability of diagnoses from telehealth services for risk adjustment,” suggesting there may be some telehealth services that might not qualify for risk adjustment. However, in the memo CMS states: “Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face ...
May 4th, 2020
Additional Telehealth Changes Announced by CMS
Published May 4th, 2020|
On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.
April 20th, 2020
Dismal OIG Report on Telemedicine
Published April 20th, 2020|
Providers need to understand the rules for reporting telemedicine services. A recent OIG report shows that this is not the case. What problems are being found in documentation claims? As providers are expanding their telehealth offerings, now is the time to understand the potential pitfalls since disallowed amounts will be taken back.
April 15th, 2020
New CPT® Codes Approved for COVID-19 Antibody Identification
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.
April 15th, 2020
CMS Temporarily Suspends Contract-Level RADV Audits
Published April 15th, 2020|
The Centers for Medicare and Medicaid Services (CMS) is suspending contract-level RADV audits, related to the payment year 2015 and will not initiate any new ones until after the public health emergency has ended. Any documentation already submitted will be reviewed as usual.
April 13th, 2020
CMS Announces Final 2021 HCC Risk Adjustment Changes
Published April 13th, 2020|
On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) published their final Medicare Advantage (MA) and Part D payment methodologies for CY 2021. Read more to be prepared for these upcoming changes.
March 24th, 2020
"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools
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: ...
March 21st, 2020
Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)
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 ...
February 10th, 2020
A 2020 Radiology Coding Change You Need To Know
Published February 10th, 2020|
The radiology section of the 2020 CPT© has 1 new, 18 revised, and 14 deleted codes. Interestingly, six of the 14 deleted codes were specific to reporting single-photon computerized tomographic (SPECT) imaging services of the brain, heart, liver, bladder, and others. If your organization reports radiology services, it is...
January 30th, 2020
Medicare Announces Coverage of Acupuncture Services
Published January 30th, 2020|
On January 21, 2020, a CMS Newsroom press-release read, This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for ...
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