Medical Payers & Insurance Companies

Accurately reporting body mass index (BMI) codes has become important with many of the payers reimbursing provider organizations up to ten dollars per chart for reporting 3008F with a documented BMI code. However, as is almost always the case, it isn't a simple scenario of collecting, documenting, and reporting the patient's BMI but rather hitting the mark on all of the criteria that goes along with it and understanding how to identify morbid obesity based on coding guidelines in the ICD-10-CM code set and specific payer policies.

This will be the third time since 2021 that the diagnosis complexity definitions have undergone significant changes. The initial 2021 changes were specific to Office and Other Outpatient E/M services and due to some confusion surrounding a few of the guidelines, updates to them were published by the AMA in April of 2021 with an effective date of January 1st. Because the 2023 E/M changes are more focused on the remaining E/M categories, especially in the hospital facility, new definitions were added and old definitions changed.

On January 1, 2023 the Evaluation and Management (E/M) Guidelines will change again but this time with a focus on all other E/M categories. These changes are very similar to the changes that took place in 2021, with scoring of the E/M service level being determined by MDM or time. The original 2021 E/M diagnosis severity definitions changed again, after implementation and with the new changes in 2023, new diagnosis definitions have been added, warranting another look at what is new and how to interpret the changes.

The 2023 Evaluation and Management changes have been published and efforts are ongoing to educate coders and provider organizations on the guideline and code description changes that will impact professional coding in the facility setting. These changes required a significant revision to the guidelines and definitions of the various levels of complexity associated with the Number and Complexity of "Problems Addressed" during an encounter, which is the first element of medical decision making (MDM) and the following explanations and examples should provide a greater understanding of the changes headed our way in January.

As of January 1, 2022, CMS created a new modifier for an unrelated E/M visit during a postoperative period. It was revised as of April 1, 2022. Learn more about the appropriate use of modifier FT.

CMS is revising its guidance and survey procedures for all provider types related to assessing and maintaining compliance with the staff vaccination regulatory requirements. This new memorandum replaces memoranda QSO 22-07-ALL Revised, QSO 22-09-ALL Revised, and QSO 22-11-ALL Revised.

Skilled Nursing Facility Provider Preview Reports: Review by November 14 - Help Your Patients Make Informed Health Care Decisions - Ambulance Fee Schedule: CY 2023 Ambulance Inflation Factor & Productivity Adjustment - Compliance - Implanted Spinal Neurostimulators: Document Medical Records - Claims, Pricers, & Codes...

Providers who actively engage in collecting and reporting social determinants of health (SDoH) open avenues of identifying and treating their patients' population health trends. Pairing chronic conditions that are difficult to control with identified SDoH circumstances such as transportation or electricity insecurity, can help identify those patients who may wish to be healthier, but who are dealing with circumstances that prevent compliance, such as transportation or access to electricity, for instance.

Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.

For the first time, ESRD Medicare beneficiaries were permitted to enroll in Medicare Advantage plans beginning in 2021. Since that time, CMS has been working to revise the program to reduce costs, improve quality, and drive benefits. Effective January 1, 2025, one such change will include a definition change for "oral-only drugs." Why is Medicare changing the definition of these drugs and how will that be a driving force in advancing care models for ESRD in the future?