PDGM Calculator for Home Health: Reminder, CMS has changed the unit of the home health payment from a 60-day episode to a 30-day period. When using the calculator, be sure that you enter the “Number of Visits” based on 30 days instead of 60 days. Read the entire article.
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April 29th, 2021
58% of Improper Payments due to Medical Necessity for Ventilators
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published April 29th, 2021
Proper documentation not only protects the provider, the payer, and the patient, it protects the integrity of the entire healthcare system. When it comes to coverage and documentation for durable medical, the DMEPOS supplier and staff must be familiar with the National and Local Coverage Determinations (NCDs and LCDs) as these are ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published October 28th, 2020
Just about any large clinic you visit will have non-physician practitioners, or NPPs. These will include physician assistants, nurse practitioners, and clinical nurses for example. Practices and clinics can bill under the NPPs if they are credentialed with the payer, but the reimbursement is only 85% of the fee schedule. There ...
By Wyn Staheli, Director of Research | Published October 1st, 2020 - Last Review/Update October 6th, 2020
New codes for Cytokine Release Syndrome (CRS) are effective October 1, 2020 based on the grade/severity of the symptoms. This article covers the new grading scales.
The additional grouper for Skilled Nursing, sometimes referred to as (PDPM), is used for classifying SNF patients in a covered Part A stay.
This grouper is included with our Home Health Grouper.
Current groupers/calculators include:
Home Health PDGM (Patient-Driven Grouping Model)
Skilled Nursing Facility PDPM (Patient-Driven Payment Model)
What is it?
According to CMS, In ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 14th, 2020
The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that ...
New CPT® Codes Approved for COVID-19 Antibody Identification
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 15th, 2020
On April 10, 2020, the American Medical Association approved and published a revision of code 86318 and added two new codes 86328 and 86769 for reporting Coronavirus [COVID-19] antibody testing.
CMS-Coverage for Therapeutic Shoes for Individuals with Diabetes
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 31st, 2020
Therapeutic shoes and inserts can play a vital role in a diabetic patient's health. Medicare may cover one pair every year and three pairs of custom inserts each calendar year if the patient qualifies and everything is handled correctly. Medicare Benefit Policy Manual explains what is needed for a person with diabetes to ...
Who Qualifies for Chronic Care Management Services
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 5th, 2020
Per MLN Chronic Care Management Services, the following patients are eligible: "Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, are eligible for CCM services."
Examples of chronic conditions ...
Preview the PDGM Calculator (HIPPS calculator) for Home Health Today
By Wyn Staheli, Director of Research | Published December 4th, 2019
Find-A-Code's Patient-Driven Groupings Model (PDGM) home health payment calculator (HIPPS Calculator) simplifies payment calculations. See https://www.findacode.com/tools/home-health/ .
New Medicare Home Health Care Payment Grouper — Are You Ready?
By Wyn Staheli, Director of Research | Published November 25th, 2019
In 2020, Medicare will begin using a new Patient-Driven Groupings Model (PDGM) for calculating Medicare payment for home health care services. This is probably the biggest change to affect home health care since 2000.
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. ...
The OIG Work Plan: What Is It and Why Should I Care?
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 Namas | Published July 19th, 2019 - Last Review/Update July 30th, 2019
Critical care services remain to not only be an area of confusion for providers, coders, and auditors, but also a constant target for the carriers for audit. We can sit back and look at critical care and think of all of the ways the code descriptor and/or use could be ...
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 ...
How to Properly Report Monitoring Patients Taking Blood-thinning Medications
By Wyn Staheli, Director of Research | Published June 18th, 2019 - Last Review/Update June 19th, 2019
Codes 93792 and 93792, which were added effective January 1, 2019, have specific guidelines that need to be followed. This article provides some guidance and tips on properly reporting these services.
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...
Documentation: Face to Face for Home Health Certification
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 9th, 2018
As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care.
Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. The ...
The Certificate of Medical Necessity (CMN) for Oxygen is a required form that helps to document the medical necessity for oxygen therapy. It also documents other coverage criteria for the oxygen use. For payment on a home oxygen claim, the information in the supplier’s records or the patient’s medical record must be substantiated with the information in the CMN.
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published January 31st, 2018
With this year's Flu season being the most widespread on record, providers are seeing more patients and giving more immunizations for influenza than normal. Here are a few things to keep in mind during this flu season.
Know the rules with your payers to ensure proper reimbursement and correct billing. For example, did you ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 4th, 2017
We can look forward to a few prospective payments for Skilled Nursing Facilities, Hospice and Inpatient Rehab; CMS released their final rule and reported on key highlights of the new FY 2018 Medicare payment rules.
CMS States, “The 2018 Skilled Nursing Facility (SNF) Prospective Payment System Final Rule increases Medicare payment rates ...
Proposed Payment Changes in 2018 and 2019 for Medicare Home Health Agencies
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published July 26th, 2017
CMS announced today the payment rates and wage index system for 2018 has a new proposed rule for Medicare Home Health Agencies. CMS stated, “The new payment system aims to encourage innovation and collaboration and to incentivize home health providers to meet or exceed industry quality standards.” The proposed rule ...
Respiratory Assist Devices (RAD) E0470 and E0471 - Billing Reminders
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 28th, 2017 - Last Review/Update July 28th, 2017
Add the KX modifier to all claims for RADs and accessories for the first through third months if all thecoverage criteria have been met.
Add the KX modifier to all claims for the fourth month and thereafter if all the coverage criteria have been met and if the physician signed and dated a ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 1st, 2017 - Last Review/Update January 16th, 2018
Care Plan oversight services is commonly done but rarely billed. The following codes can only be billed once every 30 days. The use of the following codes are determined by the complexity and approximate time spent by the physician or other health care professional within a 30-day period.
G0179
MD re-certification HHA PT
May be ...
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published March 1st, 2017 - Last Review/Update July 28th, 2017
Multi-layered, sustained, graduated, high compression bandage systems are used primarily to treat lymphedema and venous or stasis leg ulcers. A number of graduated, high-compression bandage systems products have been developed, including Profore®, Dyna-Flex®, Surepress®, Setopress®, and other similar product systems.Providers should note that the treatment of lymphedema with the application ...
Documentation: Face to Face for Home Health Certification
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 27th, 2017 - Last Review/Update August 16th, 2017
As a physician, you are responsible for providing appropriate, accurate supporting documentation of your face-to-face encounters (FTF) with your patients regarding home health care.
Analysis of the recent errors identified by the Comprehensive Error Rate Testing (CERT) Review Contractor shows a continuing increase in denials related to documentation for the FTF. ...
CMS Announces Proposed Payment Changes for Medicare Home Health Agencies for 2017 (CMS-1648-P)
By Brittney Murdock, QCC, CMCS, CPC | Published June 27th, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) announced proposed changes to the Medicare home health prospective payment system (HH PPS) for calendar year (CY) 2017 that would foster greater efficiency, flexibility, payment accuracy, and improved quality. Approximately 3.4 million beneficiaries received home health services from approximately 11,400 home ...
Skilled Nursing Facility Advance Beneficiary Notice (SNFABN) Form - Free
By Find-A-Code | Published March 8th, 2016
The purpose of this form is to help you make an informed choice about whether or not you want to receive these items or services, knowing that you might have to pay for them yourself. Before you make a decision about your options, you should read this entire notice carefully.
...
Clear the Smoke on Debridement and Active Wound Care Codes
By | Published February 26th, 2016
Confused about when to choose a debridement code and an active wound code? CPT® 2011 is here to your rescue with revised debridement code guidelines that clarify how to choose between the two code groups — and the key word that will tighten up your coding is depth. “Depth is...
Nebulizer Therapy Billing Reminders - Modifiers, Dispensing Fees, and Orders
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published February 24th, 2016 - Last Review/Update August 3rd, 2017
The ICD-10-CM code describing the condition necessitating nebulizer therapy must be included on each claim for equipment, accessories, and/or drugs.
When ever a unit dose code is billed, it must have a KO, KP, or KQ modifier. (Exception: The KO, KP, and KQ modifiers should not be used with code J7620.)
When billing miscellaneous equipment or accessories (E1399), the claim must ...
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
By Christine Woolstenhulme, QCC, QMCS, CPC, CMRS | Published August 7th, 2014 - Last Review/Update January 25th, 2017
Reimbursement for most Durable Medical Equipment, Prosthetics, Orthotics and Supplies (DMEPOS) is established by fee schedules. Payment is limited to the lower of the actual charge or the fee schedule amount.  We have given you some basic information to get you started including modifiers and how CMS views DMEPOS, please ...
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