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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Understanding the Basics of Reporting Mammography Services

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How familiar are you with the coding and documentation requirements for screening and diagnostic mammography? What is diagnostic digital breast tomosynthesis and can you bill for it? This article review the basics of reporting screening, diagnostic, and digital breast tomosynthesis.

tags  Specl: Oncology|Hematology    Specl: Radiology    Topic: Billing    Topic: Coding    Topic: CPT Coding    Topic: HCPCS Coding    Topic: ICD10CM Coding    Topic: Medicare    Topic: Modifier Coding    Topic: Preventive Medicine    Topic: Procedure Coding   

The Conundrum Presented by Outpatient Surgeries

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Do you keep them under inpatient status? Or do you bring them in as outpatients and just keep them overnight?  For our Medicare populations, in all of our organizations, the ability to follow the CPT code of the applicable surgical procedure is the determining factor to bill inpatient...

tags  Topic: Admin    Topic: Billing    Topic: Coding    Topic: Hospital    Topic: Inpatient Coding    Topic: Medicare    Topic: Practice Management    Topic: Reimbursement   

How Would Your Organization Defend This Auditing Accusation?

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The Office of Inspector General (OIG) is always working on audits in a pursuit of accurate reporting and reimbursement. A recently published OIG audit report can provide great information on how to protect providers and risk adjustment payers from serious financial losses by showing exactly what the OIG is looking for and how the payer (or provider) may have defended their coding choices. In this article, you will see how the OIG audited the HCC for major depressive disorder and what Anthem did to defend its reporting.

tags  Topic: Auditing    Topic: Coding    Topic: CPT Coding    Topic: Documentation    Topic: ICD10CM Coding    Topic: Medicare    Topic: OIG    Topic: Practice Management    Topic: Reimbursement    Topic: Risk Adjustment   

HHS’s New Mental Health and Substance Use Disorder Benefit Resources Will Help People Seeking Care to Better Understand Their Rights

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New Resources to Help People Seeking Care to Understand and Access Protections Offered Under the Parity Law for Mental Health and Substance Use Disorder Benefits

tags  Specl: Behavioral Health|Psychiatry|Psychology    Specl: Primary Care|Family Care    Topic: Admin    Topic: Billing    Topic: CPT Coding    Topic: HCPCS Coding    Topic: ICD10CM Coding    Topic: Insurance    Topic: Medicare    Topic: Reimbursement    Topic: Training   

DMEPOS Items: Medical Record Documentation

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According to MLN Connects 2022-04-21 MLNC, "For Medicare to cover any Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) item, the patient’s medical record must include enough documentation to justify the need for: Type and quantity of items ordered Frequency of use (or replacement if applicable) The medical record should include the patient’s ...

tags  Topic: Auditing    Topic: Claims Processing    Topic: Denial Management    Topic: DME   

Recent AMA Study Finds Half of Black Women Have High Blood Pressure

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Hypertension among Black Americans is among the highest in the world. Currently, the American Medical Association (AMA) is working to achieve optimal health for all. To do that, they need to work at the community level to bring health equity to minority communities in the U.S. A recent...

tags  Topic: ICD10CM Coding    Topic: Medicare    Topic: Preventive Medicine   

Making the Case for Clean Claims

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Medicare providers are your claims clean? Federal regulations mandate that 90 percent of “clean claims” must be paid to healthcare providers within 30 days. But what if the payor doesn’t pay within 30 days? What if your claims are unclean? The problem is – who determines what a...

tags  Topic: Admin    Topic: Appeals    Topic: Billing    Topic: Claims Processing    Topic: Denial Management    Topic: Medicare    Topic: Practice Management    Topic: Reimbursement   

Moving to Medical Decision-Making as the Key Component

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Office billing is now based solely on either MDM or total time. Last week, I declared that it is my opinion that medical decision-making (MDM) should always be one of the components that contributes to selecting (or perhaps, demonstrating) the appropriate level of service (LOS) for the professional...

tags  Topic: CPT Coding    Topic: E+M Documentation and Coding    Topic: Social Determinants of Health (SDOH)   

Minor Procedures Get a Major Sting in the 2021 CERT Report

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The 2021 Comprehensive Error Rate Testing report provides important lessons on exactly what errors are being found during chart reviews and how provider organizations can be proactive in their approach to quality documentation that not only supports the services provided to the patient but allows the providers to work in an environment of knowing what must be documented to support what they submit to the payer.

tags  Topic: Documentation    Topic: E+M Documentation and Coding    Topic: EHR    Topic: Medicare    Topic: Practice Management   

Continuous Glucose Monitors (CGMs) -- New Codes

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New codes for continuous glucose monitors (CGMs) became effective on April 1, 2022. The following information is excerpted from MLN Matters MM12564 regarding CGMs. Be sure to review this information and implement policies to ensure accurate reporting/billing. On December 28, 2021, we published the Medicare DMEPOS final rule in the Federal Register. This addressed the ...

tags  Topic: DME    Topic: HCPCS Coding    Topic: ICD10CM Coding    Topic: Supply Coding   

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