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This page contains articles, resources/links and tips related to *All States.

  • Articles:  57
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Is Your Organization Ready to Deal with Provider Relief Fund (PRF) Audit Contractors?

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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?

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Five Major ICD-10-CM Changes That Can Effect Your Organization

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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.

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ICD-10-CM Cracks Down on the Use of "Unspecified" in the 2021 Official Guidelines

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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.

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How Well Will Your Organization Score in the 2022 Star Rating Measures?

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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.

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Is Coding Based on Addendums or Late Entries Putting You At Risk of Audit Failure?

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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?

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Medicare Advantage - The Fastest Growing Government-Funded Program Undergoing Multiple Fraud Investigations

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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 ...

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Will CMS Allow Medicare Advantage Organizations to Risk Adjust from Audio-Only Encounters? 

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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.

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How Does Global and Professional Direct Contracting (GPDC) Affect Risk Adjustment?

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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 ...

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Managed Care Organizations Use CMS Tools to Identify Outliers

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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.

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OIG Plans for Onslaught of Risk Adjustment Audits Claiming 9.5% Error Rate in Code Assignment

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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.

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Identifying Risk-Adjusted Services During the Opioid Crisis

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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 ...

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Q/A: For E/M, How do I Count Tests Ordered in One Department and Performed in Another?

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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.

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How to Combat COVID-Related Risk Adjustment Losses with the Medicare Annual Wellness Exam

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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 ...

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How Reporting E/M Based on Time May Lose Money

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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 ...

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How Social Determinants of Health (SDOH) Data Enhances Risk Adjustment

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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.

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Looking Beyond an Employee's Coding Credentials

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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) ...

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CMS Reduces the Exchange User Fee to Support Lower Premiums for the Consumer

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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 ...

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How Might the New 2021 E/M Guideline Changes Impact Risk Adjustment?

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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 ...

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Are You Aware of the 2021 Star Rating System Updates?

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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 ...

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Delving Into the 360 Assessment Fraud Complaint

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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.

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What is the Difference Between the Medicare 1995 and 1997 Documentation Guidelines for E/M Services?

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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 ...

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2021 Brings Another Risk Adjustment Calculation Change

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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...

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Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?

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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 ...

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Additional Telehealth Changes Announced by CMS

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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.

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Dismal OIG Report on Telemedicine

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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.

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New CPT® Codes Approved for COVID-19 Antibody Identification

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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.

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CMS Temporarily Suspends Contract-Level RADV Audits

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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.

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CMS Announces Final 2021 HCC Risk Adjustment Changes

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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.

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"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools

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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: ...

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

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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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A 2020 Radiology Coding Change You Need To Know

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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...

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Medicare Announces Coverage of Acupuncture Services

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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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