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Medical ID Theft
August 16th, 2019
By Namas | Published August 16th, 2019 - Last Review/Update August 20th, 2019
Medical ID Theft
"So, do you guys think you can do something with that?" John asked angrily at our first meeting with him in August 2017 as he slammed a stack of medical bills, EOBs and collection letters - three inches high - down in front of my partner and I. ...
How to Properly Report Prolonged Evaluation and Management Services
August 13th, 2019
By Aimee Wilcox | Published August 13th, 2019
Have you ever had a patient take more time with the provider than they were scheduled for? Do you understand which codes to report and the rules that govern them to allow for better reimbursement?
Prolonged Service codes were created just for that reason but you must carefully follow the documentation ...
The OIG Work Plan: What Is It and Why Should I Care?
August 9th, 2019
By Namas | Published August 9th, 2019 - Last Review/Update August 14th, 2019
The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...
By BC Advantage | Published July 12th, 2019 - Last Review/Update July 30th, 2019
Last year was historic for HIPAA enforcement. The HHS Office of Civil Rights collected a record $23.5 million in settlements and judgments against providers guilty of HIPAA violations. To avoid becoming part of that unwanted statistic, it’s important to pay extra close attention to five key areas of HIPAA vulnerability.
Take ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 24th, 2019
Biofeedback is used for many reasons, and most commonly used for pain management. Each payer should be consulted with to verify coverage when treating with Biofeedback to verify if the treatment is considered experimental or investigational.
The majority of payers will list Biofeedback on an exclusions list. Others such as BC ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 5th, 2019
State scope of practice laws and regulations will help determine who is considered Clinical staff and Other qualified Health Care professionals.
Physician or other qualified healthcare professionals: Must have a State license, education training showing qualifications as well as facility privileges.
Examples of Qualified Healthcare professionals:
(NOTE: this list is not all-inclusive, please refer to your payer ...
Wolters Kluwer provides unit and package pricing for multiple drug price types: Average Wholesale Price (AWP), Wholesale Acquisition Cost (WAC), Direct Price (DP), Manufacturer's Suggested Wholesale Price (SWP), Centers for Medicare & Medicaid Services, Federal Upper Limit (CMS FUL), Average Average Wholesale Price (AAWP), Generic Equivalent Average Price (GEAP). Average...
Finalized Confidentiality of Alcohol and Drug Abuse Patient Records Regulations
August 31st, 2018
By Wyn Staheli, Director of Research | Published August 31st, 2018
In January, the U.S. Department of Health and Human Services (HHS) issued updates to the privacy regulations regarding the confidentiality of patient information of substance use disorder patients (42 CFR Part 2). This notice included references to better alignment with HIPAA regulations, but did state that Part 2 is more protective ...
Preventive Medicine: Counseling to Prevent Tobacco Use
May 9th, 2018
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Counseling to Prevent Tobacco Use
Procedure Codes 99406: Smoking and tobacco use cessation counseling visit; intermediate, greater than 3 minutes up to 10 minutes 99407: Smoking and tobacco use cessation counseling visit; intensive, greater than 10 minutes
ICD-10-CM 99406-99407: No specific diagnoses
Frequency 99406-99407: 2 attempts a year, ...
By Find-A-Code™ | Published May 9th, 2018 - Last Review/Update August 1st, 2018
Preventive Medicine Topics Page
Depression Screening
Procedure Codes G0444: Annual depression screening, 15 minutes 96127: Brief emotional/behavioral assessment (eg, depression inventory, attention-deficit/hyperactivity disorder [ADHD] scale), with scoring and documentation, per standardized instrument
ICD-10-CM G0444, 96127: No specific diagnoses
Frequency G0444:Once annually 96127: No specific frequency guidelines
Additional Information 96127
Only covered for ages ...
Payment Rates Increase for Behavioral Health Office Services
February 13th, 2018
By Wyn Staheli, Director of Research | Published February 13th, 2018
Behavioral health providers may see some improvement in payment rates for office-based behavioral health services. This is due to the fact that the overhead expense evaluation portion of the RVU was increased. The following information is from the Federal Register (see References):
We agree with these stakeholders that the site of service ...
By Wyn Staheli, Director of Research | Published January 25th, 2018
Psychiatric Partial Hospitalization Programs (PHPs) are a more comprehensive level of care than Intensive Outpatient Programs (IOPs - click here to read more about IOPs). When the patient requires a minimum of 20 hours per week and hospitalization is not clinically indicated, a PHP can be the most effective type of ...
Medicare's Integrated Behavioral Healthcare Services and Collaborative Care Program
January 18th, 2018
By Wyn Staheli, Director of Research | Published January 18th, 2018
Over the last several years, primary care has begun to integrate behavioral health services to better address shortfalls in patient quality of care. Some of the first codes were the Health and Behavior Assessment/Intervention (96152-96155) codes, which were added in 2002. Since then, many different models have been experimented with and have ...
Medicare Requiring Specific Modifiers on Therapy Services
January 15th, 2018
By Wyn Staheli, Director of Research | Published January 15th, 2018
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following:
Services furnished under the Outpatient ...
By Wyn Staheli, Director of Research | Published January 11th, 2018
Intensive Outpatient Programs (IOPs) are considered to be an intermediate level of care which is commonly considered after the patient has been discharged from inpatient care. For some patients and/or conditions they can also provide an effective level of care when hospitalization is not clinically indicated or preferred. The following ...
According to Wisconsin Physicians Service Insurance Corporation, there is limited coverage for the GeneSight® Psychotropic (AssureRx Health, Inc, Mason, OH) gene panel. GeneSight® testing may only be ordered by licensed psychiatrists or neuropsychiatrists contemplating an alteration in neuropsychiatric medication for patients diagnosed with major depressive disorder (MDD) (in accordance with DSM IV/V criteria) who are suffering with refractory moderate to ...
Auditing Prolonged Evaluation and Management Services
September 12th, 2017
By Aimee Wilcox | Published September 12th, 2017 - Last Review/Update September 18th, 2017
At times, there are patients who require prolonged face-to-face time with the provider to discuss or be counseled about their condition, plan of care, risks, complications, alternative therapies, or other medical issues. When E/M services go wild, taking significantly longer than the typical time associated with it, that direct face-to-face ...
Medicare Improper Payment Report for Behavioral Health Services (2016)
September 1st, 2017
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
The Medicare Improper Payment Report for 2016 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from ...
By Wyn Staheli, Director of Research | Published September 1st, 2017 - Last Review/Update October 16th, 2017
NOTICE: This table was created for use by those who have purchased a Find-A-Code specialty specific Reimbursement Guide. Please do not share with others.
Codes in bold are complete codes of the highest specificity.
Codes with ** are listed in the DSM-5 which contains diagnostic criteria.
The underscore ( _ ) means that an ...
Preventive Services: Lung Cancer Counseling and Annual Screening for Lung Cancer With LDCT
September 1st, 2017
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Lung Cancer Screening Counseling, and Annual Screening for Lung Cancer With Low Dose Computed Tomography (LDCT)....
Preventive Services: Screening for STIs and High Intensity Behavioral Counseling (HIBC) to Prevent STIs
September 1st, 2017
By Find-A-Code | Published September 1st, 2017 - Last Review/Update January 31st, 2018
The following information from the Medicare Learning Network provides guidance on Screening for Sexually Transmitted Infections (STIs) and High Intensity Behavioral Counseling (HIBC) to Prevent STIs.....
New payments for Psychiatric Collaborative Care Services (COCM) from Medicare
June 29th, 2017
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 29th, 2017
Medicare has agreed to make separate payments to physicians and non-physicians for Behavioral Health Integration (BHI) services beginning Jan. 1st, 2017.
Any condition new or pre-existing behavioral health or substance use disorders are eligible. Beneficiaries may have comorbid, chronic, or other medical conditions they are being treated for as well.
Using the ...
Psychiatric / Psychological Testing with Bill Type 12X
June 23rd, 2017
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 23rd, 2017 - Last Review/Update July 26th, 2017
Providers submitting claims with bill type 12X are to report revenue code 0918 (psychiatric / psychological testing).
Note:
Revenue codes do not apply to physicians; other professionals and suppliers bill these services to the Part B MAC
They are used only with providers who bill these services to the fiscal intermediary or Part ...
By Wyn Staheli, Director of Research | Published February 21st, 2017
Telehealth (also known as telemedicine) is playing an ever increasing roll in the reimbursement process. Internet services continue to expand and many insurance payers/providers are now covering (paying for) telehealth services. Telepsychiatry (providing behavioral health services in a telehealth environment) has been highly successful because video conferencing makes providing psych ...
By Wyn Staheli, Director of Research | Published February 16th, 2017
In order to arrive at a diagnosis and check for related complications, a healthcare provider needs to evaluate the patient condition. This may include:
History: This can include the patient's personal history as well as that of the patient's family.
Physical exam: The healthcare provider will try to rule out physical problems ...
By Wyn Staheli, Director of Research | Published February 6th, 2017
The Medicare and Medicaid incentive programs are different. The Medicare EHR incentive program has been incorporated into the new Quality Payment Program (QPP). However, providers may be unaware that there is still a Medicaid EHR incentive program. The time period for signing up for the Medicaid EHR incentive program ended in 2016. ...
By Wyn Staheli, Director of Research | Published February 2nd, 2017
Of special interest to all behavioral health practitioners (both Covered Entities and NON-covered entities) is HIPAA's provision for psychotherapy notes. The privacy rule recognizes that psychotherapy notes need more protection than other types of PHI. Even if you are not a covered entity, we recommend understanding and implementing office procedures ...
Alternative Payment Models (APMs) and Advanced APMs
January 16th, 2017
By Wyn Staheli, Director of Research | Published January 16th, 2017
When CMS Released the NPRM regarding the Quality Payment Program (QPP), it included two payment tracks: MIPS and Advanced Alternative Payment Models (APMs). Accountable Care Organizations (ACOs), Patient Centered Medical Homes, and bundled payment models are some examples of APMs. So how do these payment models differ?
According to a fact sheet ...
By Wyn Staheli, Director of Research | Published December 12th, 2016
Effective March 14, 2016, the CMS Final Rule clarifying the standards for handling
overpayments for both Medicare and Medicaid takes effect. Failure to report and
subsequently return an overpayment within 60 days after the overpayment was
“identified” is a violation of the False Claims Act.
By Wyn Staheli, Director of Research | Published December 7th, 2016
Workers’ Compensation is for work related illness or injuries on the job. The employer pays for insurance which covers medical costs incurred, and replaces lost wages. Fees are based on a specific fee schedule that varies by state.
There are three possible scenarios regarding workers’ compensation: the patient is covered by ...
By Wyn Staheli, Director of Research | Published October 1st, 2016 - Last Review/Update October 16th, 2017
The UB-04 is the claim form to be used for billing facility services. This article lists some of the common codes that behavioral healthcare providers would use when billing these types of services. Always verify payer policies regarding their preferred codes.
Note: A more comprehensive list of codes for the UB-04 ...
By Wyn Staheli, Director of Research | Published September 17th, 2016
The Department of Health and Human Services (HHS) oversees all government health care programs. They are administered by various agencies such as the Centers for Medicare & Medicaid Services (CMS), the Veterans Administration (VA) and even at the state level. Here are the basic government programs:
Medicare
Federal Workers’ Compensation
Military and Veterans
Medicaid
Federal ...
Certified Community Behavioral Health Clinics (CCBHC) Moving Forward
May 3rd, 2016
By Wyn Staheli, Director of Research | Published May 3rd, 2016
Certified Community Behavioral Health Clinics (CCBHCs) were created in an effort to improve access and outcomes behavioral healthcare by providing community-based mental and substance use disorder treatment through an integrative approach to care.
By Instacode Institute | Published April 5th, 2016 - Last Review/Update January 2nd, 2019
Providers need to understand that even though there are now federal laws, state laws are often different. It is important to ascertain patient coverage before treatment begins. This article contains some federal laws which address mental health services.
By Wyn Staheli, Director of Research | Published March 29th, 2016
Performance Measurement Codes for Behavioral Health:
Although there are hundreds of Performance Measurement (PM) services and events, only a few could be reported for behavioral health services for the 2014 reporting year. For 2014, there were seventeen PQRS measurements that could relate to behavioral health services:
Anti-depressant Medication Management
9
Medication Reconciliation
46
Advance Care Plan
47
Adult ...
By Wyn Staheli, Director of Research | Published March 29th, 2016
Performance Measurement Codes for Behavioral Health:
Although there are hundreds of Performance Measurement (PM) services and events, only a few could be reported for behavioral health services for the 2015 reporting year. For 2015, the following PQRS measurements are those that are most likely to relate to behavioral health services:
Anti-depressant Medication ...
By Wyn Staheli, Director of Research | Published March 16th, 2016
The Comprehensive Addiction and Recovery Act (CARA) is proposed new legislation to address the growing problem of heroin, prescription drugs, and opioid pain relievers abuse issues by Improving programs to help states monitor and track prescription drug diversion “and to help at-risk individuals access services.”
ABN is required - (if you anticipate payer will deny or is not medically necessary)
February 23rd, 2016
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 23rd, 2016 - Last Review/Update August 3rd, 2017
An ABN may be used for services which are likely to be non-covered, whether for medical necessity or for other reasons. Refer to CMS Publication 100-04, Medicare Claims Processing Manual, Chapter 30, for complete instructions.Effective from April 1st, 2010, non-covered services should be billed with modifier –GA, -GX, -GY, or –GZ, ...
List of approved ICD-10 codes for Mental Health Providers - Washington State Medicaid
February 15th, 2016
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 15th, 2016
The agency covers the below outpatient services to treat conditions that fall within the ICD diagnosis code range for mental health. For billing purposes, providers are required to use the most specific code available.
The agency also covers preventative mental health care, if the most specific code is used.
See the agency’s ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published June 17th, 2015
Both DSM-5 and ICD-9 codes are used for diagnosis and are exactly the same codes. For reporting purposes it is required to report ICD-9 codes to insurance payers. Most payers require ICD-9 codes to be billed on electronic or paper claims. Therefore, the codes are the same in DSM as ...
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
April 28th, 2015
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published April 28th, 2015 - Last Review/Update January 25th, 2017
FACT SHEET
April 24, 2015
Contact: CMS Media Relations
(202) 690-6145 | CMS Media Inquiries
Proposed FY 2016 Medicare Payment And Policy Changes For Inpatient Psychiatric Facilities
OVERVIEW: On April 24, 2015, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule outlining proposed fiscal year (FY) 2016 Medicare payment policies and ...
By Wyn Staheli, Director of Research | Published March 31st, 2015 - Last Review/Update June 9th, 2016
Under contract with the federal government, the Substance Abuse and Mental Health Services Administration (SAMHSA) recently released revised the Federal Guidelines for Opioid Treatment Programs (OTPs). The agency indicates that the guidelines “should be the primary reference and central measure for program staff, accreditation bodies and other stakeholders on the delivery ...
By Wyn Staheli | Published March 26th, 2015 - Last Review/Update July 27th, 2017
The Diagnostic and Statistical Manual for Mental Disorders (DSM) is the standard classification of mental disorders used by mental health professionals in the United States. It is generally accepted as the authoritative guide for the diagnosis of mental disorders. This FAQ article was created to address some commonly asked questions about DSM coding and clear up some common misconceptions.
By Wyn Staheli, Director of Research | Published March 6th, 2015 - Last Review/Update February 18th, 2016
In an effort to improve quality of care in nursing home, CMS has been reviewing PQRS quality measures and offering provider training through a variety of mediums. Antipsychotic drug use is just one of the measures being reviewed. The MLN Connects Provider eNews for February 12, 2015 included the following notice about ...
Medicare's Screening, Brief Intervention, and Referral to Treatment (SBIRT) Services
November 17th, 2014
By Wyn Staheli, Director of Research | Published November 17th, 2014 - Last Review/Update January 6th, 2017
Medicare understands that there are individuals who may not meet the diagnostic criteria for substance abuse, but who are still at risk. To help identify these individuals and take steps to keep them from reaching the level of abuse, Medicare has established a program called the Screening, Brief Intervention, and ...
HHS Announces $99 Million in New Grants to Improve Mental Health Services for Young People
September 25th, 2014
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
Health and Human Services Secretary Sylvia M. Burwell announced today $99 million to train new mental health providers, help teachers and others recognize mental health issues in youth and connect them to help, and increase access to mental health services for young people.
Read the article here: HHS.gov
...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 25th, 2014 - Last Review/Update January 30th, 2017
Questions and Answers for Psychologists and PQRS. In 2007, Psychologists had very limited opportunity to participate in PQRS. As of 2014, there are 11 measures available for claims-based reporting and two for registry reporting.
For the entire article read more here: PracticeCentral.org
Below are the 11 new measures for 2014
Major depressive disorder: diagnostic evaluation (#106)
Major ...
By Wyn Staheli, Director of Research | Published September 15th, 2014 - Last Review/Update July 12th, 2016
Many procedure codes are considered "timed codes," that is, the number of units are determined by the amount of time spent performing the service. Medicare Claims Processing Manual, Chapter 5 clarification included here.
Compliance specialists are responsible for monitoring health and human services program operations for compliance with federal and state regulations and standards in order to promote health and safety, assure that public services are delivered properly, or prevent fraud. Areas assessed may include service delivery, eligibility determination and payment, medical reimbursement, ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published July 29th, 2014 - Last Review/Update January 25th, 2017
Integrated healthcare is a coordinated approach between Primary Care Providers and Behavioral health providers. This program is to detect, treat and ensure follow up for mental and physical conditions. The system was created to integrate and share information with an interdisciplinary health care team to create better continuity of care. ...
By Wyn Staheli, Director of Research | Published January 1st, 2014 - Last Review/Update October 4th, 2017
There are numerous types of behavioral health screening tools for healthcare providers. Some, like the AUDIT and SBIRT are especially applicable to primary care providers caring for Medicare beneficiaries.
This page includes some general information and resources for some of these screening tools. Let us know if you would like others included ...
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