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September 2nd, 2021

Polysomnography Services Under OIG Scrutiny

By Raquel Shumway | Published September 2nd, 2021

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

August 17th, 2021

When is it Proper to Bill Nurse Visits using 99211

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 17th, 2021

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

August 16th, 2021

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

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published August 16th, 2021

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

August 12th, 2021

Billing Dental Implants under Medical Coverage

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 12th, 2021

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

August 10th, 2021

New Codes for COVID Booster Vaccine & Monoclonal Antibody Products

By Wyn Staheli, Director of Research | Published August 10th, 2021

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

August 4th, 2021

Understanding How Place of Service Codes Work

By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 4th, 2021

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

August 2nd, 2021

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

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published August 2nd, 2021

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

July 29th, 2021

Medicare's ABN Booklet Revised

By Wyn Staheli, Director of Research | Published July 29th, 2021

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

July 19th, 2021

Chronic Pain Coding Today & in the Future

By Wyn Staheli, Director of Research | Published July 19th, 2021

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

July 15th, 2021

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

By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published July 15th, 2021

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 ...