Medical Specialties

articles, webinars, links, files and other resources related to coding, reimbursement and compliance for medical specialties

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recent articles

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​​Polysomnography Services Under OIG Scrutiny


The OIG conducted a study dated June 2019 wherein they indicated that there were approximately $269 million in overpayments for polysomnography services for the period of 2014 through 2015. According to the OIG “These errors occurred because the CMS oversight of polysomnography services was insufficient to ensure that providers complied with Medicare requirements and to prevent payment of claims that didn’t meet those requirements.” So what are those requirements?

tags  Topic: Coding    Topic: CPT Coding    Topic: Denial Management    Topic: Documentation    Topic: Medicare    Topic: Reimbursement   

When is it Proper to Bill Nurse Visits using 99211


When vaccines or injections are given in the office, coding can often get confusing; for example, is it correct to report a nurse visit using 99211 and an E/M office visit reporting 99202 ‑ 99215 and include injection fees with the vaccine product? In addition, the reporting of evaluation and management (E/M) during the same visit ...

tags  Specl: Billing    Topic: CPT Coding   

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


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 ...

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

Billing Dental Implants under Medical Coverage


Implants can be costly to the patient and the provider, and it is crucial to understand how to bill a patient’s medical insurance to ensure there is adequate coverage for the best treatment. Implants are commonly billed in a dental office under a patient’s medical benefits.    Implants could be considered ...

tags  Specl: Dental    Specl: Oral and Maxillofacial Surgery    Topic: CPT Coding   

New Codes for COVID Booster Vaccine & Monoclonal Antibody Products


New codes have been announced for the COVID-19 booster vaccine, Novavax vaccine, and monoclonal antibody treatment.

tags  Topic: Admin    Topic: Code Updates    Topic: Coding    Topic: COVID-19    Topic: CPT Coding    Topic: HCPCS Coding    Topic: Procedure Coding   

Understanding How Place of Service Codes Work


The Place of service (POS) codes are used by CMS, Medicaid, and other private insurance to indicate where medically related items and services are sold or dispensed for a patient. POS codes are used for professional billing and are required to be reported on each claim submitted on a CMS-1500 ...

tags  Specl: All Specialties    Topic: Claims Processing    Topic: Coding    Topic: CPT Coding    Topic: Modifier Coding    Topic: POS - Place of Service   

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


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   

Medicare's ABN Booklet Revised


The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.

tags  Payer: CMS|Medicare    Specl: All Specialties    Topic: ABN - Advanced Beneficiary Notice    Topic: Compliance    Topic: CPT Coding    Topic: HCPCS Coding   

Chronic Pain Coding Today & in the Future


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?


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   

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