Medical Payers & Insurance Companies

articles, webinars, links, files and other resources related to coding, reimbursement and compliance for medical payers and insurance companies


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recent articles

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Chronic Pain Coding Today & in the Future

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Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.

tags  Specl: All Specialties    Topic: Diagnosis Coding    Topic: ICD-11 Coding    Topic: ICD10CM Coding   

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 ...

tags  Loc: All Locations    Payer: Medicare Advantage Plans    Specl: Risk Adjustment|HCC Coding    Topic: Risk Adjustment   

How to Properly Assign ICD-10-CM Codes for Pain

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Pain is a common diagnosis among all specialties so it should not be surprising to find there are 162 ICD-10-CM codes for reporting it and over 80 mentions in the ICD-10-CM Official Guidelines for Coding and Reporting which describe when certain types of pain should be reported and how the codes should be sequenced.

tags  Specl: Acupuncture|Alternative    Specl: Allergy|Immunology    Specl: Anesthesia|Pain Management    Specl: Behavioral Health|Psychiatry|Psychology    Specl: Cardiology|Vascular    Specl: Dermatology|Plastic Surgery    Specl: Emergency Medicine    Specl: Endocrinology    Specl: ENT|Otolaryngology    Specl: Gastroenterology    Specl: General Surgery    Specl: Home Health|Hospice    Specl: Internal Medicine    Specl: Interventional Radiology    Specl: Laboratory|Pathology    Specl: Neurology|Neurosurgery    Specl: Obstetrics|Gynecology    Specl: Oncology|Hematology    Specl: Ophthalmology    Specl: Optometry    Specl: Oral and Maxillofacial Surgery    Specl: Orthopedics    Specl: Pain Management    Specl: Pediatrics    Specl: Physical Medicine|Physical Therapy    Specl: Podiatry    Specl: Primary Care|Family Care    Specl: Pulmonology    Specl: Rheumatology    Specl: Risk Adjustment|HCC Coding    Specl: Skilled Nursing    Specl: Urology|Nephrology    Topic: Diagnosis Coding    Topic: ICD10CM Coding   

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.

tags  Loc: All Locations    Payer: All Payers    Specl: Risk Adjustment|HCC Coding    Topic: Risk Adjustment   

Compliance in the Dental Office or Small Practice

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If your practice does not already have a compliance program in place, you will want to get started after reading this article. We have uncovered some important findings with the Office of Inspector General (OIG) in dental practices you need to be aware of. A compliance program offers standard procedures to follow, ...

tags  Specl: All Specialties    Specl: Dental    Topic: Claims Processing    Topic: Compliance   

UCR Anesthesia Fee Calculations and Base Units - Now Available!

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As per customer request, Find-A-Code now offers UCR Anesthesia Fee Calculations along with CMS and ASA. The anesthesia fee calculations can be found under the Fees section of the code and under the Anesthesia Fee Information.   Time units are computed by dividing the reported anesthesia time by 15 minutes (17 minutes / 15 minutes = 1.13 units). NOTE: Always ...

tags  Payer: VA - Veterans Administration    Specl: Anesthesia|Pain Management    Topic: Billing    Topic: Coding    Topic: CPT Coding    Topic: Fees    Topic: Life Care Planners    Topic: UB04 Form and Coding   

Important Changes to Shared/Split Services

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Reporting of split (or shared) services has always been wrought with the potential for incorrect reporting when the fundamental principles of the service are not understood. A recent CMS publication about these services further complicates the matter.

tags  Topic: CPT Coding    Topic: E+M Documentation and Coding    Topic: Procedure Coding   

Understanding Non-face-to-face Prolonged Services (99358-99359) in 2021

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Due to the extensive changes in office or other outpatient services (99202-99215), there are many questions which still need to be answered, one of which is related to the prolonged services without face-to-face contact. This article explores the question regarding the appropriate use of codes 99358/99359 and how to report it.

tags  Specl: All Specialties    Topic: CPT Coding    Topic: E+M Documentation and Coding    Topic: HCPCS Coding   

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.

tags  Loc: All Locations    Payer: All Payers    Payer: Medicare Advantage Plans    Specl: Risk Adjustment|HCC Coding    Topic: Auditing    Topic: Coding    Topic: Diagnosis Coding    Topic: Documentation    Topic: Fraud    Topic: ICD10CM Coding    Topic: Risk Adjustment   

Chronic Care Management Services

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This article discusses some of the different Chronic Care Management (CCM) Services found in both the CPT and HCPCS code sets. CCM is not the same as Case Management Services in that case management has to do with “coordinating, managing access to, initiating, and/or supervising'' patient healthcare services whereas CCM services also require the patient to have a condition(s) which is expected to last at least a year or until their death.

tags  Specl: Behavioral Health|Psychiatry|Psychology    Specl: Primary Care|Family Care    Topic: CPT Coding    Topic: HCPCS Coding    Topic: Preventive Medicine    Topic: Procedure Coding   

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