Select the title to see a summary and a link to the full article.
November 12th, 2019
HIPAA Final Rule Eliminates HPID and OEID
By Wyn Staheli, Director of Research | Published November 12th, 2019
Final rule eliminates the requirement for health plans to obtain a unique health plan identifier (HPID) and also eliminates the voluntary use of the other entity identifier (OEID). This change becomes effective December 27, 2019.
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 11th, 2019
Find-A-Code offers fees and pricing for just about everything, this article will address two of some of the most common payment systems with CMS. (OPPS) -Outpatient Medicare Outpatient Prospective Payment System. (MPFS)- Medicare Physician Fee Schedule The Fees section on each code page is determined on the type of services...
Medically Unlikely Edits (MUEs): Unlikely, But Not Always Impossible
By Namas | Published October 18th, 2019 - Last Review/Update October 23rd, 2019
Medically Unlikely Edits (MUEs) were created by the Centers for Medicare & Medicaid Services (CMS) to help lower the error rate for paid Part B claims. MUEs are the maximum units of a HCPCS or CPT code that a provider would bill under most circumstances for the same patient on ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 15th, 2019
Genetic testing is becoming very popular. In fact, so popular you might see it in places you would not expect such as a community event, fairs or any event happening in your community. Some labs may even offer FREE screening for genetic testing. Watch for FREE screening announcements or advertisements ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 15th, 2019
Have you noticed your LCDs are missing something? CMS is moving codes out of LCDs and into Billing and Coding Articles. MACs began moving ICD-10-CM, CPT/HCPCS, Bill Type, and Revenue codes in January 2019, and will continue through January 2020. Therefore, if there is an LCD with its codes removed, you will find ...
By Namas | Published October 11th, 2019 - Last Review/Update October 15th, 2019
Why is HIPAA So Important?
Some may think that what they do to protect patient information may be a bit extreme. Others in specialty medical fields and research understand its importance a little more. Most of that importance lies in the information being protected. Every patient has a unique set of ...
2020 Official ICD-10-CM Coding Guideline Changes Are Here!
By Wyn Staheli, Director of Research | Published October 1st, 2019
It’s that time of year for offices to get ready for the ICD-10-CM code revisions. As part of that process, it’s also good to know what is going on with the ICD-10-CM Official Guidelines for Coding and Reporting. In the examples listed below, strikeout text is deleted and highlighted text ...
By Wyn Staheli, Director of Research | Published October 1st, 2019
When federal employees sustain work-related injuries, it does not go through state workers compensation insurance. You must be an enrolled provider to provide services or supplies. The following are some recommended links for additional information about this program.
Division of Federal Employees' Compensation (DFEC) website
Division of Federal Employees' Compensation (DFEC) provider ...
Do ICD-10 Updates Have Your Heart Beating Irregularly? Check Out the New Atrial Fibrillation Codes
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 1st, 2019
Atrial fibrillation (AF) is the most common type of abnormal heart rhythm (arrhythmia). It is caused by a disorder in the heart’s electrical system. AF is the result of abnormal contractions of the atria (upper two chambers of the heart) causing them to quiver and beat out of sync with ...
The New ICD-10-CM Code Updates Are Here — Are You Ready?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published October 1st, 2019
Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99)
A small revision in the description changed[STEC] to (STEC) for B96.21, B96.22, B96.23. Remember, in the instructional guidelines, ( ) parentheses enclose supplementary words not included in the description (or not) and [ ] brackets enclose synonyms, alternative wording, or explanatory phrases.
Chapter 2: ...
CMS and HHS Tighten Enrollment Rules and Increase Penalties
By Wyn Staheli, Director of Research | Published September 30th, 2019
This ruling impacts what providers and suppliers are required to disclose to be considered eligible to participate in Medicare, Medicaid, and Children's Health Insurance Program (CHIP). The original proposed rule came out in 2016 and this final rule will go into effect on November 4, 2019.
There have been known problems ...
Are You Aware of Medicare Advantage Plans Timely Filing Rules?
By Aimee Wilcox | Published August 20th, 2019
The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial.
As any company who has billed Medicare services can attest, the one-year timely filing ...
How to Properly Report Prolonged Evaluation and Management Services
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?
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 ...
Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage
By Namas | Published July 26th, 2019 - Last Review/Update August 8th, 2019
Anthem has been very busy sending out notices stating that, beginning October 1, 2019, all timely filing deadlines for claims will be 90 days. We've seen this letter, or something very similar, sent to doctors and other healthcare providers from California to Kentucky.
In their notice, Anthem states:
"Effective for all commercial ...
By Wyn Staheli, Director of Research | Published July 22nd, 2019
There are many things that can be missed when trying to run an effective and profitable practice. This article covers some important tasks that are often overlooked such as not reviewing your payer contracts or failing to check eligibility.
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 ...
Helping Others Understand How to Apply Incident to Guidelines
By Namas | Published July 5th, 2019 - Last Review/Update July 16th, 2019
Over the past few months, I have worked with different organizations that have been misinterpreting the "incident to" guidelines and, in return, have been billing for services rendered by staff that are not qualified to perform the services per AMA and CPT. What I found within the variances is that ...
2018 Medicare Improper Payment Report Shows Slight Improvement but There's Still Work to be Done
By Wyn Staheli, Director of Research | Published June 27th, 2019 - Last Review/Update July 8th, 2019
The Medicare Improper Payment Report for 2018 is not a measurement of fraud. Rather, it is an estimate of the claims paid by Medicare which did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from July 1, 2016 through June 30, 2017, was 91.9 percent. ...
By Namas | Published June 21st, 2019 - Last Review/Update June 27th, 2019
Small Breaches Can Be Subject to Large Penalties
We may have heard about the large fines issued by the Office for Civil Rights (OCR) against big organizations like Anthem or the University of Texas MD Anderson Cancer Center. These organizations have been in the news due to privacy breaches that constituted violations ...
Risk Adjustment is a program that was implemented to identify and support Medicare beneficiaries with health conditions, illnesses, or injuries that put them at risk of death or organ system/bodily function failure. Through Risk Adjustment (RA), Medicare ensures their beneficiaries are being followed at least annually for any healthcare conditions ...
By Namas | Published June 14th, 2019 - Last Review/Update June 18th, 2019
A United Approach
As auditors, we all have a different perspective when evaluating documentation. It would be unreasonable to think that we all view things the same way. In my opinion, differing perspectives are what makes a great team because you can coalesce on a particular chart, work it through and ...
What Medical Necessity Tools Does Find-A-Code Offer?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 13th, 2019
Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published June 6th, 2019 - Last Review/Update June 11th, 2019
Have you ever tried to quickly recall the elements required to support a comprehensive ophthalmologic exam versus an intermediate one? Make coding decisions quickly by creating a cheat sheet containing vital information that allows you to quickly select the right code.
According to Article A19881 which was published in 2004 and ...
Noting "Noncontributory" for Past Medical, Family, Social History - Is It Acceptable?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 29th, 2019 - Last Review/Update June 4th, 2019
Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?
RT and LT Modifier Usage Change (effective 2019-03-01)
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published May 21st, 2019
According to Noridian Medicare, there are new changes required when reporting the RT and LT modifier(s). In the past, it was appropriate to bill the RT and LT modifier on the same line when it was required for certain HCPCS codes. Noridian released a publication stating claims reported with RT/LT on the same ...
An Update on the DHS OIG's Effort to Combat Fraud & Abuse
By Namas | Published May 17th, 2019 - Last Review/Update May 21st, 2019
An Update on the DHS OIG's Effort to Combat Fraud & Abuse
Every year, the Department of Health and Human Services (DHS) Office of Inspector General (OIG) is required by law to release a report detailing the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such ...
By Wyn Staheli, Director of Research | Published April 29th, 2019
On April 12, 2019, Medicare announced that there will be some changes to their appeals process effective June 13, 2019. According to the MLN Matters release (see References), the following policy revisions in the Medicare Claims Processing Manual (MCPM), Chapter 29 are taking place:
The policy on use of electronic signatures
Timing ...
By Wyn Staheli, Director of Content | Published April 26th, 2019
There are policy revisions in the Medicare Claims Processing Manual (MCPM), Chapter 29 taking place June 13, 2019. This will give you a heads up on those changes.
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.
Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...
What is Medical Necessity and How Does Documentation Support It?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published April 23rd, 2019
We recently fielded the question, “What is medical necessity and how do I know if it's been met?"
The AMA defines medical necessity as:
It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...
By Wyn Staheli, Director of Research | Published April 8th, 2019
Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...
Q/A: Can I Tell a Medicare Patient Which Option to Check on the ABN?
By Wyn Staheli, Director of Research | Published April 1st, 2019 - Last Review/Update April 2nd, 2019
Question
My patient seemed confused about which of the options they should check. Can I just tell them which one they should check?
Answer
No! That could be construed as coercion. The official instructions state “Under no circumstances can the notifier decide for the beneficiary which of the 3 checkboxes to select.”
Now, this ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 27th, 2019
When coding with ICD-10-CM, pain codes can be found in different sections:
The Body System affected or site-specific pain codes, such as Low Back Pain M54.5, can be found in Chapter 13. Diseases of the Musculoskeletal system (M00-M99). Other examples might be ocular pain H57.1, found in Chapter 7. Diseases of ...
Clearing Up Some Medicare Participation Misunderstandings
By Wyn Staheli, Director of Research | Published March 25th, 2019 - Last Review/Update April 2nd, 2019
Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for ...
Q/A: How do we Know Which Codes a Payer Will Allow?
By Wyn Staheli, Director of Research | Published March 22nd, 2019
How do we know which codes a payer will allow?
The best way to determine the codes (CPT, ICD-10-CM and HCPCS) allowed by a payer is to review their payer policy. While it is good to know the official guidelines (e.g., ICD-10-CM Official Guidelines for Coding and Reporting, AMA Guidelines, Medicare ...
The Impact of Medical Necessity on High Level E/M Services
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 21st, 2019
I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?"
The quick answer is, "it depends."
Code 99233 has the following minimal component requirement:
Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 18th, 2019
If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all ...
Q/A: Can you Help me Understand the New Medicare Insurance Cards?
By Wyn Staheli, Director of Research | Published March 7th, 2019
As many of you are aware, CMS began issuing new Medicare identification cards last year which required the replacement of social security numbers with a new Medicare Beneficiary Identifier (MBI). All cards have now been mailed out and patient's should have the new cards when they come in. Currently, we are in the transition period until January 2020.
UnitedHealthcare to Discontinue Coverage of Consultations
By Wyn Staheli, Director of Research | Published March 4th, 2019 - Last Review/Update March 7th, 2019
In United Healthcare's March provider bulletin, they announced that beginning on June 1, 2019, they will be phasing out coverage of consultation services (99241-99255).
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 1st, 2019
Medicare creates and maintains the National Correct Coding Initiative (NCCI) edits and NCCI Policy Manual, which identify code pair edits. When performed on the same patient, on the same day, and by the same provider, the secondary code is considered an integral part of the primary code, and payment for ...
Proposed Rule: Expanded Telemedicine Benefits for Medicare Advantage Beneficiaries
By Aimee Wilcox | Published February 14th, 2019
Telemedicine continues its rise, with new technologies allowing for better communication and access to more aspects of healthcare than ever before. Each year Medicare has made strides, albeit small strides, in their telemedicine coverage while commercial payers continue to make great strides, constantly improving and expanding telemedicine service offerings to ...
Detection by Nucleic Acid (DNA or RNA) - Amplified Probe Technique
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 13th, 2019
This question was asked on the following lab codes used for testing during pregnancy. "Can the codes below be billed together? 87491- 59, 87591-59. 87081, 87150."
YES- CPT code 87081 is used when a specific pathogen is suspected and is appropriate.
YES- (X2) 87150 is used for culture, typing, and identification by nucleic ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 12th, 2019
The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward.
Purpose
An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...
By Wyn Staheli, Director of Research | Published February 7th, 2019 - Last Review/Update February 8th, 2019
Question
Are you aware if digital x-ray of the spine requires a different code than plain x-ray? If so, where can I find the information specific to digital x-ray codes?
Answer
There are no separate codes for digital x-rays. However, there may be modifiers that are required to be submitted with the usual ...
Attestations Teaching Physicians vs Split Shared Visits
By BC Advantage | Published February 1st, 2019 - Last Review/Update February 7th, 2019
Physicians often use the term "attestation" to refer to any kind of statement they insert into a progress note for an encounter involving work by a resident, non-physician practitioner (NPP), or scribe. However, for compliance and documentation purposes, "attestation" has a specific meaning and there are distinct requirements for what ...
By Find-A-Code | Published January 28th, 2019 - Last Review/Update January 29th, 2019
BLOG: CMS announced a NEWS release today making it easier to help Medicare Beneficiaries access cost and quality information. CMS announced, "Today, the Centers for Medicare & Medicaid Services (CMS) launched a new app that gives consumers a modernized Medicare experience with direct access on a mobile device to some of ...
By NAMAS | Published January 28th, 2019 - Last Review/Update January 29th, 2019
NAMAS needs your help in capturing salary information for 2018 and developing standards for the industry. This is the information that YOU as an auditor need to share with your employer!
Everyone who participates will be entered into a drawing for a chance to win one of many prizes! One winner ...
Medical Necessity vs. Documentation for Inpatient Services
By NAMAS | Published January 25th, 2019 - Last Review/Update January 29th, 2019
Auditing the documentation of inpatient and observation E/M services can often be challenging. Many of the notes we are provided for review include so much information that the note feels like a short novel instead of documentation for one date of service. This over-documentation can make it difficult to see ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 23rd, 2019
We have it all! Search our WK Drug Database for drugs and pharmaceuticals. When it comes to support and guidance the WK Drug Database offers a paramount search and is conveniently presented in one place.
Pricing
GPIs
NDCs
Billing Codes
Indications/Diseases
Packaging Information
Active and Inactive
and more...
Additionally, learn more about drugs and pharmaceuticals that can be used to detect, treat, or monitor ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2019
Modifier 62 is appended to surgical claims to report the need for the skills of two surgeons (co-surgeons) to perform a procedure, with each surgeon performing a distinct part of the same procedure, during the same surgical session.
An easy way to explain this is to visualize a patient requiring cervical fusion where ...
Are You Protecting Your Dental Practice From Fraud?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 10th, 2019
With the expansion of dental coverage through Medicaid and Medicare Advantage plans, an ever-increasing number of dental claims have come under scrutiny for fraud. One such payer, Aetna, is actively pursuing dental fraud by employing their special investigative units (SIUs) to identify and investigate providers who demonstrate unusual coding and ...
By Wyn Staheli, Director of Research | Published January 3rd, 2019
The correct coding of dry needling, also known as trigger point needling, has been a subject of confusion for quite some time. The American Chiropractic Association (ACA) and the American Physical Therapy Association (APTA) have been working together for several years to obtain appropriate codes to describe this service. In ...
By Wyn Staheli, Director of Research | Published January 3rd, 2019
Back in August of 2018, as part of the Medicare Shared Savings Program (Shared Savings Program), CMS proposed some sweeping changes for Accountable Care Organizations (ACOs). There has been some controversy over these changes which require ACOs to move to two-sided models. In this Final Rule which was scheduled to be published in the Federal Register ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 3rd, 2019
For 2019 a new code has been introduced (81443) which represents genetic testing for 15 genes associated with severe, inherited conditions. The results of this test may be used to identify carrier status during prenatal genetic counseling, confirm a clinical diagnosis, or identify at-risk family members for the following severe ...
Errors Billing Outpatient Services When Patient is also Inpatient
By Wyn Staheli, Director of Research | Published November 29th, 2018
The OIG recently reported that Medicare inappropriately paid acute-care hospitals for outpatient services provided to patients who were inpatients of another facility including long term care hospitals, inpatient rehabilitation facilities, inpatient psychiatric facilities, and critical access hospitals. CMS suggests using the following resources to ensure compliance:
Medicare Inappropriately Paid Acute-Care Hospitals for ...
Q/A: Do Croft Guidelines Apply After Time has Passed Since the Accident?
By Tom Grant Jr. DC | Published November 28th, 2018
Question: Do the Croft Guidelines apply to a patient's condition immediately following the collision or are they applicable to a patient's state when they first come to see you? Whether that has been weeks or months since the collision without treatment?
Reciprocal Billing and Locum Tenens Arrangements Changes
By Wyn Staheli, Director of Research | Published November 26th, 2018
CMS has made changes to their payment policies for reciprocal billing arrangements and Fee-For-Time compensation arrangements (formerly referred to as locum tenens arrangements). Providers need to be aware of these changes and update their policies as appropriate.
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...
By Wyn Staheli, Director of Research | Published October 16th, 2018
Question:
I am a certified DOT medical examiner and have applied to get my CLIA lab (waiver) for urinalysis, finger prick blood tests for A1c, cholesterol and glucose. I realize I cannot diagnose patients with these tests, but I am using them to make decisions in the DOT process and with ...
Join QPro Today and Get Certified!
To have a credential in the medical profession shows you have met a minimum standard for professional and ethical standards.
Often employers prefer to hire staff that will be involved with any type of patient information such as coding, to show proof they have met certain ...
Finalized Confidentiality of Alcohol and Drug Abuse Patient Records Regulations
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 ...
By Wyn Staheli, Director of Research | Published August 20th, 2018
Noridian's pilot program Provider Self-Audit with Validation and Extrapolation (PSAVE) has been extended which means that it has been successful for the payer, which means that they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program. Are the benefits worth the costs?
By Wyn Staheli, Director of Research | Published August 16th, 2018
Medicare's guidelines for reporting of timed codes is found in Medicare Claims Processing Manual Chapter 5, Section 20.2. Also known as the '8 minute' rule, it describes how to calculate time for appropriate reporting when more than one timed code is performed at the same time.
It should be noted that while ...
On July 16th 2018, anyone subscribed to the CMS Quality Payment Program received an e-mail containing a letter to doctors from Seem Verma, Administrator of the Centers for Medicare and Medicaid Services (CMS). There are some widespread changes proposed in this letter of which you need to be aware.
Where ...
Documentation: Face to Face for Home Health Certification
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Wyn Staheli, Director of Research | Published June 14th, 2018
On May 11, 2018, the Department of Veterans Affairs (VA) released its final rule on the "Authority of VA Health Care Providers to Practice Telehealth." Effective June 11, 2018, VA providers will be able to provide telehealth services across state lines. This move will make it easier for veterans to obtain ...
As per MLN MM8304,
This article is based on Change Request (CR) 8304, which instructs DME MACs to implement requirements, which are effective July 1, 2013, for detailed written orders for face-to-face encounters conducted by the physician, PA, NP or CNS for certain DME items as defined in 42 CFR 410.38(g).
Due to concerns ...
Q/A: Someone Broke into My Office. What do I do Now?
By Wyn Staheli, Director of Research | Published April 23rd, 2018 - Last Review/Update January 24th, 2019
My office was broken into last night. I use electronic health records, but we do store some protected health information for my patients in paper files. These files are not secured, so the burglars did have access to them. It did not appear that the files were touched as the burglars were looking for cash. What responsibilities to I have to my patients in a situation like this? Do I need to contact them and advise them that their PHI could have been compromised?
The PSAVE Pilot Program: Should You Self-Audit Your Medicare Claims?
By Robert Liles, JD, MBA, MS | Published April 20th, 2018 - Last Review/Update April 25th, 2018
As the Medicare program has grown, the Centers for Medicare and Medicaid Services (CMS) has employed a variety of different claims audit mechanisms to better ensure that the Medicare Trust Fund is protected from waste, fraud and abuse....
By Wyn Staheli, Director of Research | Published April 12th, 2018
Billing nutrition counseling services may not be as straight-forward as you might think. Some providers mistakenly choose Medical Nutrition Therapy (MNT) codes (97802-97804, G0270, G0271) because it states nutrition therapy in the title. However, according to CPT guidelines, when MNT assessment and/or intervention is performed by a physician or qualified healthcare professional who may report evaluation and management ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published March 29th, 2018
Find-A-Code presented a webinar on “Coding and Auditing Telemedicine Services,” on March 29, 2018, which did not include the new and updated CMS information published in the MNL Matters Number: MM10393 on January 2, 2018. New and exciting changes were introduced in this article, which is addressed below.
Originating Site Fee
Each ...
By Wyn Staheli, Director of Research | Published March 13th, 2018 - Last Review/Update January 31st, 2019
Question: I have a provider that provides Department of Transportation (DOT) exams. I have found ICD-10 code Z02.4 (encounter for examination for drivers license) but I am unsure which CPT Code to use. Would I still use 99203 or 99204?
By Wyn Staheli, Director of Research | Published March 1st, 2018
On February 9, 2018, the Bipartisan Budget Act of 2018 was signed into law. There were some changes which will affect Medicare payments. The following is a brief summary, for a more comprehensive summary see the References.
Therapy Caps: Some therapy caps (e.g., occupational, physical therapy, speech-language pathology) were discontinued. However, modifier KX will ...
The opportunities for providers who want to provide telemedicine continue to expand in all sectors of the healthcare market. Even the VA, long a symbol of a fossilized, bureaucratic healthcare entity, has begun to embrace this technology. Though most are familiar with what telemedicine is, many still have questions surrounding ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published February 21st, 2018
HCPCS level II codes classify products into categories for the purpose of claims processing. HCPCS level II codes are alphanumeric with a descriptive terminology that identifies the item or service used primarily for billing purposes.
There are several types of HCPCS level II codes such as:
Permanent National Codes
Dental Codes
Miscellaneous Codes
Temporary National ...
HIPAA Breach Settlements and Ransomware Attacks - Is Your Practice Secure?
By Wyn Staheli, Director of Research | Published February 5th, 2018
Two recent reports should make providers stop, take notice and make sure their practice's policies and procedures are up-to-date.
The first one involves a HIPAA Breach settlement of a company with facilities in several states. The OCR memo stated "In addition to a $3.5 million monetary settlement, a corrective action plan ...
By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published February 2nd, 2018 - Last Review/Update February 7th, 2018
This week we had a great question posted to our online forum, and I thought it would be a nice thought- provoking question for our auditing and compliance tip of the week.
By Wyn Staheli, Director of Research | Published February 1st, 2018
Healthcare providers must be vigilant in ensuring that software upgrades, also known as patches, are kept current. Failure to do so can lead to a HIPAA Security Breach with all its associated penalties. For example Windows XP no longer has security updates and should not be used in healthcare settings.
On ...
By Wyn Staheli, Director of Research | Published February 1st, 2018
On January 16, 2018, the OIG released a report of their findings on claims data for Medicare Advantage plans. While it appears that there were not significant issues, they did find that:
"Types of potential errors included inactive or invalid billing provider identifiers; duplicated service lines; missing required data; inconsistent dates; ...
If you are hesitant about collecting co-pays, consider that you may be paying interest on credit cards, property mortgages, and business loans. Each dollar that you do not collect in co-pays could have been used to pay down the practice debt. Without question, if you are having difficulty finding ways ...
By Wyn Staheli, Director of Research | Published February 1st, 2018
CMS and some other payers have adopted policies of reducing payments when certain multiple diagnostic imaging procedures (see Applicable Codes below) are performed in a single session by the same healthcare provider and/or group. They have done the same when there are multiple units for a procedure code. The rationale ...
By Ashley Choate | Published January 31st, 2018 - Last Review/Update March 29th, 2018
High Deductible Health Plans (HDHPs) are recent and growing trend in healthcare that is probably here to stay, regardless of the future changes to the national healthcare system or federal regulations.....
By Chris Woolstenhulme, QCC, CMCS, 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 ...
Dental and Medical- Controlled Substance Awareness
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2018
As an effort to cut down on opioid abuse and related crimes, in August of 2017 the Attorney General Sessions established a new Department of Justice (DOJ) section called “Opioid Fraud and Abuse Detection Unit”. Due to the serious public health issue and drug overdose deaths, this unit was established and ...
Referring and Ordering Physician - CMS-1500 Box 17
By Christine Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2018
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in Item ...
Aftercare visit codes cover situations when the initial treatment of a disease has been performed, and the patient requires continued care during the healing or recovery phase, or for the long-term consequences of the disease. The aftercare Z code should not be used if treatment is directed at a current, ...
By Sean M. Weiss, CHC, CEMA, CMCO, CP MA, CPC-P, CMPE, CPC | Published January 26th, 2018 - Last Review/Update February 7th, 2018
This year (2018), health care organizations (Hospitals, Health Systems and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency....
By Ashley Choate | Published January 24th, 2018 - Last Review/Update March 29th, 2018
According to a recent Physicians Practice study, one of the top five reasons for denied medical claims is a lack of adequate documentation. While this might seem like an electronic records issue, the problem may be bigger than that. ...
Revenue Cycle 101: Reduce your Denials with These Tips
By Ranadene Tapio, MBA, CMRS, CMC | Published January 24th, 2018 - Last Review/Update March 29th, 2018
Your practice seems to be doing everything right. You have a team in place, established your RCM process and you’re submitting claim after claim – but your denial rate isn’t going down....
NEW on Find-A-Code...National Coverage Determinations (NCDs)
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published January 23rd, 2018 - Last Review/Update January 25th, 2018
Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...
By Wyn Staheli, Director of Research | Published January 16th, 2018
Section 1848(r)(4) of MACRA requires that claims submitted for items and services furnished by a physician or applicable practitioner on or after January 1, 2018, include codes for the following:
care episode groups
patient condition groups
patient relationship categories
Previously, CMS decided to use procedure code modifiers to report patient relationship codes on Medicare ...
Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines
By Find-A-Code | Published January 11th, 2018
The Advance Beneficiary Notice of Noncoverage (ABN), Form CMS-R-131 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 1, 2010, non-covered services should be billed with modifier GA, GX, GY, or GZ, as ...
Filing a CMS-1500 Claim form to Medicare PUB-100 40.1.1.1
By Find-A-Code | Published January 4th, 2018
An independent clinical laboratory may file a paper claim form shall file Form CMS-1500 for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90.
An independent clinical laboratory that submits claims in paper format) may not combine non-referred (i.e., ...
Special Skilled Nursing Facility (SNF) Billing Exceptions for Laboratory Tests PUB-100 40.4
By Find-A-Code | Published January 4th, 2018
When a SNF furnishes laboratory services directly, it must have a Clinical Laboratory Improvement Act (CLIA) number or a CLIA certificate of waiver, and the laboratory itself must be in the portion of the facility so certified. Normally the A/B MAC (A) makes payment under Part B for clinical laboratory ...
For independent RHCs, laboratory services provided in the RHC’s laboratory are not included in the all-inclusive rate payment to the RHC and may be billed separately to the A/B MAC (B). This includes the six basic laboratory tests required for certification as well as any other laboratory tests provided in ...
Modifiers 54-55, split surgical and postoperative care
By Find-A-Code | Published January 4th, 2018
54 -Surgical care only; Surgeon is performing only the preoperative and intra-operative care
55 - Postoperative management only; Physician, other than surgeon, assumes all or part of postoperative care
Modifiers should be placed on the surgical code
Used on 10 day and 90 day surgical procedures
Both the surgeon and the physician providing the postoperative ...
According to the official ICD-10-CM Guidelines, in situations of maltreatment (e.g., adult and child abuse, neglect, etc.), the sequence of coding is important. Regardless of whether it is suspected or confirmed, it is important to document the type of abuse. Use the following sequence:
An appropriate code from category T74- (confirmed) or T76- (suspected)
Any accompanying mental ...
By Kelly Ogle, BSDH, MIOP, CMPM, CHOP | Published December 29th, 2017 - Last Review/Update January 31st, 2018
In each practice, there are patients who present with a multitude of problems. These problems can range from the smallest of symptoms to the more complex illnesses.....
Properly documenting DME orders is crucial for reimbursement. It should be noted that without meeting the payer requirements, the claim will be denied. For Medicare, the beneficiary will not be responsible for paying for the item if the provider and/or supplier do not meet requirements. Commercial payers have similar policies so carefully ...
Accreditation and Billing for Office Based Surgery (OBS)
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 18th, 2017
The traditional healthcare has seen many changes over the years, one of the newest changes we are seeing is procedures once being done as an inpatient, then as an outpatient and now from the outpatient facility to Office-Based procedures. For an Office or Provider to be eligible to perform Office-Based Surgery the ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 11th, 2017
CMS posted new Merit-based Incentive Payment System (MIPS) resources on Quality Payment Program Resource Library webpage:
CMS Web Interface: Excel template for uploading sample beneficiary data with corresponding user guide and instructional video
Extreme and Uncontrollable Circumstances Fact Sheet: Overview of the policy established in the interim final rule with comment period to support clinicians affected by the California wildfires and ...
By Wyn Staheli, Director of Research | Published November 30th, 2017 - Last Review/Update February 5th, 2019
Q: In order to code carpal tunnel syndrome G56.01 or G56.02, does there need to be documentation that nerve conduction (EMG testing) has been performed to confirm the diagnosis?
By Sean Weiss, CHC, CEMA, CMCO, CPMA, CPC-P, CMPE, CPC | Published November 17th, 2017 - Last Review/Update January 31st, 2018
I want this story that I am about to share with you to fit with the majority of clients that I represent and work with because I have represented clients with refund demands as small as $1,000 and clients who had demands greater than $30 million. This year has been ...
By Grant Huang, CPC, CPMA | Published November 3rd, 2017 - Last Review/Update January 31st, 2018
With CMS looking to gradually revise its E/M documentation requirements to reduce the burden and complexity they pose to providers, it's a great time to review the trickiest E/M component: medical decision making (MDM)....
By Shannon DeConda, CPC, CPC-I, CEMC, CEMA, CPMA, CRTT | Published October 20th, 2017 - Last Review/Update January 31st, 2018
When coding an E/M visit in the emergency department, would you count all PFSH listed even if they don't pertain to the indication as to why the patient arrived?
By David Glaser, JD | Published October 13th, 2017 - Last Review/Update January 31st, 2018
An earlier coding tip explained that the oft-repeated "if it isn't written, it wasn't done" is good risk management advice, but not a legal truism.....
Acronyms and Abbreviations: When You Fall into the Grey Area
By Omega Renne, CPC, CPMA, CPCO, CEMC, CIMC | Published October 6th, 2017 - Last Review/Update February 1st, 2018
We've all been there... you are coding or auditing, and then a note comes up that is not like the ones you've reviewed before. The language is unclear, the acronym(s) could mean so many different things, and it's hard to get a straight answer about whether or not it's supported higher or lower....
By Shannon Cameron, MBA, MHIIM, CPC | Published September 29th, 2017 - Last Review/Update January 31st, 2018
Big data and its use in the healthcare spectrum has proven to be an incredible source of the knowledge and has rapidly abetted progress in seemingly all areas of healthcare......
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published September 20th, 2017
CMS recently released a new LCD for Jurisdiction F, Bladder/Urothelial Tumor Markers (L36680).
Documentation Requirements
The medical record must clearly identify the number and frequency of bladder marker testing. Medical record documentation must be legible, must be maintained in the patient’s medical record (hard copy or electronic copy), and must meet the ...
By Shannon DeConda, CPC, CPC-I, CEMC, CMSCS, CPMA, CEMA | Published September 15th, 2017 - Last Review/Update January 31st, 2018
Have you looked for published guidance on cloning/copying and pasting from the Centers for Medicare & Medicaid Services (CMS)? There is one published resource that provides rudimentary guidance.....
Double Dipping in the History of the Evaluation and Management Note
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published September 14th, 2017
There are many rules and guidelines a coder must be aware of when it comes to appropriately selecting an Evaluation and Management (EM) code and avoiding doubling dipping is one of them. Double dipping occurs when the same information is used in more than one of the subcomponents of history.
The subcomponents of history include:
Chief Complaint ...
Auditing Prolonged Evaluation and Management Services
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 ...
ICD-10-CM Coding Advice for Healthcare Encounters in Hurricane Aftermath
By BC Advantage | Published September 12th, 2017 - Last Review/Update January 25th, 2018
This document is intended to be used as a guide to help coding professionals when coding healthcare encounters of those individuals affected by a hurricane.
Global Surgical Package: When to Bill and When Not to Bill, that is the Question
By Stephanie Allard, CPC, CEMA, RHIT | Published September 8th, 2017 - Last Review/Update January 31st, 2018
The global surgical package is inclusive of the services that would normally be provided to the patient following surgery. Depending on the global period assigned to a CPT code, the pre-operative, intra-operative and post-operative services could be included in the global surgical package.....
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 ...
By Find-A-Code | Published September 1st, 2017 - Last Review/Update February 2nd, 2018
The following information from the Medicare Learning Network provides guidance from the Department of Health and Human Services on Cardiovascular Disease Screening Tests:
80061 -
Lipid panel, this panel must include the following:
82465 - Cholesterol, serum, total
83718 - Lipoprotein, direct measurement, high density cholesterol (HDL cholesterol)
84478 - Triglycerides
Z13.6
All Medicare beneficiaries without apparent signs or symptoms ...
Preventive Services: Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)
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 Intensive Behavioral Therapy (IBT) for Cardiovascular Disease (CVD)....
Preventive Services: Lung Cancer Counseling and Annual Screening for Lung Cancer With LDCT
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
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.....
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 Pelvic Examinations (includes a clinical breast examination)....
By Sean Weiss, CHC, CMCO, CEMC, CPMA, CMPE, CPC-P, CPC | Published August 25th, 2017 - Last Review/Update January 31st, 2018
On June 29th, The Centers for Medicare and Medicaid (CMS) issued the Medicare Program: "Changes to the Medicare Claims and Entitlement, Medicare Advantage and Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures final rule."
The Veterans Choice Program, created in 2014, was part of the solution to the extensive waiting times found in the VA system. The program allowed veterans to meet their health care needs from private health care providers. Though the “sunset” of the program was avoided earlier in the year, the ...
VA Patient-Centered Community Care and Veterans Choice Program: Worth it for Providers?
By Jared Staheli | Published August 23rd, 2017
As the opportunities for providers outside the VA system expand in order to meet demand, you may be interested in offering services to veterans and the VA, if you are not already. With overwhelming bipartisan support, the opportunities are not likely to abate, but are those opportunities worth it for ...
By Wyn Staheli, Director of Research | Published August 4th, 2017
An article by Medical Economics highlights the June report of the Health Care Industry Cybersecurity Task Force. Their report confirmed once again that healthcare providers are not adequately addressing cybersecurity as part of the compliance programs. The threat of hackers is very real and providers need to ensure that they have taken ...
By Wyn Staheli | Published August 4th, 2017 - Last Review/Update October 4th, 2017
Medicare has proposed making some changes to policies regarding telehealth services. They are adding some new codes to their covered list of telehealth services and propose eliminating the requirement to use the GT modifier. Since many payers adopt similar policies, watch for further announcements from other third-party payers.
Proposed Codes
HCPCS code G0296 ...
In 2017, President Trump signed into law changes to the Veteran's Choice program, which allows veterans to seek care from a civilian (privately contracted) healthcare provider, closer to home, when obtaining care through the VA has become burdensome to the veteran or requires the veteran to wait too long for an appointment.
By Wyn Staheli, Director of Research | Published August 1st, 2017
Annual Wellness Visits (AWVs) are a preventive medicine service. It is a comprehensive evaluation and management service which is covered by payers as part of the Affordable Care Act (ACA)'s covered services and there are typically no deductibles or co-pays.
By Valora Gurganious, MBA, CHBA | Published July 7th, 2017 - Last Review/Update January 25th, 2018
Technology is ubiquitous in modern society, and just when we thought that computers could not replace the "human touch" of a healthcare provider, technology is making specialized care accessible to patients anywhere there is an internet connection.
By Liz Wilson, RHIT, CCS, CDIP, CPC, CRC, CEMC | Published June 30th, 2017 - Last Review/Update January 31st, 2018
Evaluation and Management (E/M) codes are defined by the AMA Current Procedural Terminology (CPT®) codebook and while they are the most commonly utilized CPT codes, their code descriptions have not changed in years.
By Wyn Staheli, Director of Research | Published April 10th, 2017
On February 3, 2017, the Department of Justice (DOJ) issued a Final Rule to increase the civil monetary penalties assessed under the False Claims Act (FCA), due to inflation for the year 2017, to an all-time high of $10,957 (minimum) to $21,916 (maximum). Thirty years ago, in 1986, Congress amended the False ...
By Wyn Staheli, Director of Research | Published March 29th, 2017
The final sub-component of Medical Decision Making is the Risk of Significant Complications, Morbidity and/or Mortality. The following is the official Evaluation and Management Table of Risk. The level is selected by choosing one element from three criteria (Presenting Problem, Diagnostic Procedures Ordered, and Management Options), with the highest level selected ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017
The official guidelines for ICD-10-CM have very specific rules in determining principal diagnosis. However, it is imperative to note that it is necessary to be aware of the coding conventions in the ICD-10-CM Tabular List and Alphabetic Index as they take precedence over the official coding guidelines. Also, consider the ...
Z Codes That May Only be Principal/First-Listed Diagnosis
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017
The following Z codes/categories may only be reported as the principal/first-listed diagnosis, except when there are multiple encounters on the same day and the medical records for the encounters are combined:
Z00 Encounter for general examination without complaint, suspected or reported diagnosis Except: Z00.6 Z01 Encounter for other special examination without complaint, suspected ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017
When the medical documentation submitted is inadequate to support payment for the services billed, it may be determined that the claim contained insufficient documentation. If the claims reviewer is unable to conclude the services, some or all, were actually provided, they may determine the claim is unprocessable or incomplete. There are ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017
Effective July 1, 2013, certain DME/HCPCS codes require a valid detailed written order prior to delivery. There are very specific rules and requirements requiring medical necessity and orders/prescriptions. It is also required to keep a copy in the patients chart. If billing CMS and commercial payers payers, the DME prescribed ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published March 2nd, 2017 - Last Review/Update July 28th, 2017
Some Durable Medical Equipment, Prosthetics, Orthotics, and Supplies (DMEPOS) items require a detailed Written Order Prior to Dispensing (WOPD), while others require a Detailed Written Order (DWO) prior to billing. The specific requirements for an order are specified in the Medical Policy (Local Coverage Determination and/or Policy Article) for the ...
How to Properly Dispose Protected Health Information (PHI)
By InstaCode Institute | Published February 27th, 2017
HIPAA requires covered entities to properly dispose of Protected Health Information (PHI) in the following manner:
Paper, film, or other hard copy media has been shredded or destroyed such that the PHI cannot be read or otherwise cannot be reconstructed.
Electronic media has been cleared, purged, or destroyed consistent with NIST Special Publication 800-88, Guidelines for Media ...
By Wyn Staheli, Director of Research | Published February 23rd, 2017
In June 2015, the Office of Inspector General (OIG) issued a Fraud Alert focused on physicians and compensation arrangements. Providers need to ensure that these arrangements do not violate the Anti-Kickback Statute. Healthcare providers found to have committed fraud are subject to possible criminal, civil and administrative sanctions.
In this alert ...
By Wyn Staheli, Director of Research | Published February 23rd, 2017
Telehealth is proving to be the wave of the future as the number of practices offering these services continues to grow. An online poll by Medical Economics asked those who visited their site about the implementation of telehealth services implemented by their individual practices this year. As of February 2, 2017, the results were significant:
30% ...
By Wyn Staheli, Director of Research | Published February 11th, 2017
The following modifiers are required when reporting medically necessary routine foot care services per Medicare guidelines:
Q7: One Class A finding
Q8: Two Class B findings
Q9: One Class B and two Class C findings
Appropriate: With foot care (podiatry) codes to indicate covered foot care
Inapproriate:
With any code not related to foot care
When the foot ...
By Wyn Staheli, Director of Research | Published February 8th, 2017
In April of 2015, the Sustainable Growth Rate (SGR) formula which is used to calculate the Medicare Physician Fee Schedule (MPFS) Conversion Factor was repealed as part of the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). The conversion factor will increase by 0.5% each year until 2019 and ...
By Wyn Staheli, Director of Research | Published February 6th, 2017
On January 17, 2017, a Final Rule was published in the Federal Register outlining changes to the Medicare Appeals process in an order to streamline procedures and reduce the current backlog of appeals at the third and fourth levels of appeal. This new policy takes effect on March 20, 3017. ...
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 ...
Clinical Scenario for Coding with ICD-10-CM: Abdominal Pain
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 31st, 2017 - Last Review/Update August 2nd, 2017
Chief Complaint
• “My stomach hurts and I feel full of gas.”
History
• 47 year old male with mid-abdominal epigastric pain, associated with severe nausea & vomiting; unable to keep down any food or liquid. Pain has become “severe” and constant.
• Has had an estimated 13 pound weight loss over the past ...
Code Sets - Health Care Provider Taxonomy Code Set Link
By Raquel Shumway | Published January 24th, 2017
Every Provider needs to know their Health Care Provider Taxonomy Codes. The Taxonomy Codes define the provider type, classification, and area of specialization. We have provided a link and instructions to help you locate your code.
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 23rd, 2017 - Last Review/Update March 8th, 2017
Deleted Codes for Drug Screening, the following codes are no longer valid for services performed on or after January 01, 2017.
Deleted Codes for 2017
80300
Drug screen, any number of drug classes from Drug Class List A; any number of non-TLC devices or procedures, (eg, immunoassay) capable of being read by direct optical ...
Alternative Payment Models (APMs) and Advanced APMs
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 Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published December 13th, 2016
Risk Adjustment models are used to calculate risk scores used in predicting average beneficiaries healthcare expenditures. Currently Medicare Advantage and Prescription Drug programs include a risk adjustment as a component of the bidding and payment process to standardize bids, compare bids, and adjust plan payments. If you are not familiar ...
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 December 7th, 2016
All healthcare providers need to be aware that there are both appropriate and inappropriate ways to discount your fees. Both state and federal laws can impact your practice financial policy regarding fee discounts. Additionally, we recommend carefully reviewing either Chapter 1.5-Fees of the Behavioral Health DeskBook or the Insurance and Reimbursement chapter ...
Product Wastage Documentation Requirements and Reporting: Using JW Modifier
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published November 28th, 2016 - Last Review/Update August 1st, 2017
When using the JW modifier for Part B drug claims for discarded drugs and biologicals, any amount of wasted material should be clearly documented in the medical record with the following information:
Date, time, and location of treatment
Approximate amount of product unit used
Approximate amount of product unit discarded
Reason for the wastage
Manufacturer’s serial/lot/batch ...
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 ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 30th, 2016
ICD-10 expands sections on poisonings and toxins.
When documenting injuries, include the following:
1. Episode of Care e.g. Initial, subsequent, sequelae 2. Injury site Be as specific as possible3. Etiology How was the injury sustained (e.g. sports, motor vehicle crash, pedestrian, slip and fall, environmental exposure, etc.)?4. Place ...
Documentating Diabetes Mellitus, Hypoglycemia and Hyperglycemia
By Find-A-Code | Published August 30th, 2016
The Increased Specificity in ICD-10-CM means documentation must more specific to accommodate the complications and combinations used. The diabetes mellitus codes are combination codes that include the type of diabetes mellitus, the body system affected, and the complications affecting that body system.When documenting diabetes, include the following:1. Type e.g. Type 1 ...
Smoking and tobacco cessation counseling, covered indications and # of visits
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 23rd, 2016 - Last Review/Update August 2nd, 2017
Nationally Covered Indications:Effective for claims with dates of service on or after August 25, 2010, CMS will cover tobacco cessation counseling for outpatient and hospitalized Medicare beneficiaries1. Who use tobacco, regardless of whether they have signs or symptoms of tobacco-related disease;2. Who are competent and alert at the time that ...
Medicare Will Use Private Payor Prices to Set Payment Rates for Clinical Diagnostic Laboratory Tests Starting in 2018
By Brittney Murdock, QCC, CMCS, CPC | Published June 23rd, 2016
Today, the Centers for Medicare & Medicaid Services (CMS) released a final rule implementing Section 216(a) of the Protecting Access to Medicare Act of 2014 (PAMA), requiring laboratories performing clinical diagnostic laboratory tests to report the amounts paid by private insurers for laboratory tests. Medicare will use these private insurer ...
By Wyn Staheli, Director of Research | Published June 21st, 2016
When a claim has been determined to be paid more than the allowed amount, it is considered an overpayment. The action to be taken depends on how the overpayment is discovered. This article covers voluntary overpayment refund procedures as well as a Voluntary Overpayment Form.
Mastering Medicare: When Opting Out is not an Option
By Dr. Ray Foxworth, Certified Medical Compliance Specialist and President of ChiroHealthUSA | Published June 15th, 2016 - Last Review/Update March 5th, 2019
Unlike MDs and DOs, chiropractors may not opt out of Medicare.
When it comes to Medicare, providers and patients alike feel like beating their heads against the wall. Signing up to be a provider or a patient is confusing, understanding what is covered is confusing and just about the time you think you have it figured out, you receive a notice that suggests you don’t.
The hassles of Medicare certainly validate any sane person questioning whether they should see a Medicare patient, but with the rising number of Medicare patients in the US do you really want to limit your patient base?
Understanding and Using Taxonomy Codes to Maximize Reimbursement
By | Published June 9th, 2016
Taxonomy codes are used by insurers as indicators of legal scope of practice. Scope of practice is key to getting reimbursed under the Affordable Care Act or ObamaCare. However, Most providers will only choose one taxonomy code to describe their training. This limits their scope of practice. To maximize scope ...
By InstaCode Institute | Published March 29th, 2016
Download CMS's Preferred PQRS Measures Lists by Specialty. 17 Specialties to choose from. Find out exactly what CMS is expecting to see reported for your specialty.
Employee Exclusions Screenings Must be High Priority
By Wyn Staheli | Published February 24th, 2016
Many healthcare organizations are not aware of how critically important it is to screen their employees against ALL state and federal exclusions databases. This article has important information for organization to ensure compliance.
Will Incident-To in Your Organization Pass a Compliance Audit?
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published February 1st, 2016
Practices that bill incident to services need to periodically audit compliance with Medicare and private payor guidelines to avoid potential denials or third-party audits.
Announcing Find-A-Codes newest addition - Medical /Lab Test Information
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2016
Announcing Find-A-Codes Newest product: Medical /Lab Test Information, available with your Find-A-Code subscription.Test information includes:
overview of the test
utility - when/why/how the test is used
diseases the test is often used to detect or monitor
specimen collection methods/procedures
testing methodology
usual turnaround time
interpretation of test results
reference ranges for test results (normal, abnormal, etc.)
diagnosis and billing ...
Certificate for Provider - Performed Microscopy Procedures
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 29th, 2016
Effective January 19, 1993, a laboratory that holds a certificate for provider-performed microscopy procedures may perform only those tests specified as provider-performed microscopy procedures and waived tests, as described below, and no others.
HCPCS Code Test
Q0111
Wet mounts, including preparations of vaginal, cervical or skin
specimens
Q0112
All potassium hydroxide (KOH)
preparations
Q0113
Pinworm examinations
Q0114
Fern test
Q0115
Post-coital direct, qualitative ...
6 ways to stop filing duplicate Medicare claims - Duplicates could expose your practice to fraud investigation
By | Published January 6th, 2016
Whenever a Medicare Administrative Contractor (MAC) releases a list of the top reasons for claims denials, the list almost never fails to include duplicate claims. When the MAC perceives the claim to be a duplicate, based typically on a match of the patient identifying information, furnishing...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 23rd, 2015
A laboratory may be licensed or exempted from licensure in several major categories of procedures. These major categories are listed in the Pub 100 Chapter 16-Labratory Services.
...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 21st, 2015
Effective September 1, 1992, all laboratory testing sites (except as provided in 42 CFR 493.3(b)) must have either a CLIA certificate of waiver, certificate for provider -performed microscopy procedures, certificate of registration, certificate of compliance, or certificate of accreditation to legally perform clinical laboratory testing on specimens from individuals in ...
Clinical Laboratory Improvement Amendments (CLIA) program MLN Matters Article
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published October 21st, 2015
The Clinical Laboratory Improvement Amendments (CLIA) establishes a program to regulate laboratories that perform testing on patient specimens to ensure accurate and reliable test results. This fact sheet discusses:
■ Overview of the CLIA program;
■ Test categories;
■ How to enroll;
■ Types of certificates;
■ CLIA Proficiency Testing (PT); and
■ Resources
Read Entire article: ...
By Wyn Staheli, Director of Research | Published October 5th, 2015
One of the significant coding changes with ICD-10-CM was including laterality within the code itself. This concept should help reduce billing errors and claim denials. Interestingly, CMS issued a statement regarding the reporting of laterality in their provider newsletter (emphasis added).
Implementation of ICD-10-CM will not change the reporting of Current Procedural Terminology ...
Opting out of Medicare Electing to Order/Certify Items and Services to Medicare Beneficiaries
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 10th, 2015
Physicians and practitioners who do not wish to enroll in the Medicare program may “opt-out” of Medicare. This means that neither the physician, nor the beneficiary submits the bill to Medicare for services rendered. Instead, the beneficiary pays the physician out-of-pocket and neither party is reimbursed by Medicare. A private ...
Procedures Not Subject to Fee Schedule When Billed With Blood Products (Rev. 1, 10-01-03)
By Find-A-Code | Published July 10th, 2015
The following codes are not subject to fee schedule limitations when submitted for payment on the same bill with charges for blood products. Rather, assume they are to be used for blood matching and not for diagnostic purposes.
Codes: 86901, 86905, 86930-86932, 86920-86922, 86890, 86870, 86891, 86880-86886, 86971, and 86930.
If no ...
Method of Payment for Clinical Laboratory Tests - Place of Service Variation (Rev. 2971, 07-07-14)
By Jared Staheli | Published July 9th, 2015
The following apply in determining the amount of Part B payment for clinical laboratory tests:
Laboratory tests not payable on the Clinical Diagnostic Laboratory Fee Schedule (CLFS) will be based on OPPS (for hospitals subject to OPPS) and current methodology for hospitals not subject to OPPS.
Independent laboratory or a physician or ...
(Rev. 3086, Issued: 10-03-14, Effective: ICD-10: Upon Implementation of ICD-10, ASC X12: January 1, 2012, Implementation ICD-10: Upon Implementation of ICD- 10; ASC X12: November 4, 2014) The standards adopted under HIPAA include both a transaction standard and an implementation guide. The following are the claims transactions and the implementation ...
By Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content | Published May 11th, 2015 - Last Review/Update January 30th, 2017
Modifier 33 for Preventive Care
With the implementation of modifier 33 and its complicated and unique description, many coders have wondered how to properly apply it. Let's review the information we have on the modifier and see if we can better understand how and when to use it.
Modifier 33 was created ...
By Find-A-Code | Published May 7th, 2015 - Last Review/Update June 9th, 2016
Personal Injury is an complicated subject as it relates to medical services. This page contains helpful information as an additional resource to Find-A-Code's specialty-specific Reimbursement Guides.
By Raquel Shumway | Published March 17th, 2015 - Last Review/Update June 9th, 2016
We have two different samples for Patient Information Forms. We suggest that you review both and determine which best fits your practice model. Form #2 is editable so it could be easily modified for your organization. Both forms provide the basic information necessary for all types of healthcare practices.
Instructions for: Patient ...
By | Published February 10th, 2015 - Last Review/Update February 18th, 2016
The Centers for Medicare & Medicaid Services (CMS) uses a network of contractors called Medicare Administrative Contractors (MAC) to process Medicare claims, enroll health care providers in the Medicare program and educate providers on Medicare billing requirements. MACs also handle claims appeals and answer beneficiary and provider inquiries. Even though ...
By Wyn Staheli, Director of Research | Published February 3rd, 2015 - Last Review/Update June 9th, 2016
Even though the health care system in the United States is one of the most expensive per capita in the world, we have a dismally low quality of care ranking. Healthcare reform (HCR) in its simplest terms is addressing these shortcomings in order to improve healthcare coverage, delivery, policies, or ...
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published January 16th, 2015 - Last Review/Update March 1st, 2016
Billing for Split Unit of Blood
(Rev. 1487, Issued: 04-08-08, Effective: 04-01-08, implementation: 04-07-08)
HCPCS code P9011 was created to identify situations where one unit of blood or a blood product is split, and some portion of the unit is transfused to one patient while the other portions are transfused to other patients ...
By | Published November 5th, 2014 - Last Review/Update January 30th, 2017
Anyone who uses modifier 59 needs to be aware that due to problems with the incorrect usage of this modifier (which by the way is also revised for 2015,) CMS has added four new HCPCS modifiers. An announcement by CMS stated that "CMS is establishing four new HCPCS modifiers to define subsets of the -59 modifier, a modifier used to define a “Distinct Procedural Service.”
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, ...
Q & A: What is the Definition of "New Patient" for Billing Evaluation and Management (E/M) Services?
By Chris Woolstenhulme, QCC, CMCS, CPC, CMRS | Published August 26th, 2014 - Last Review/Update August 9th, 2017
Q: What is the definition of "new patient" for billing evaluation and management (E/M) services?
A: Interpret the phrase "new patient" to mean a patient who has not received any professional services, i.e., evaluation and management service or other face-to-face service (e.g., surgical procedure) from the physician or physician group practice ...
Durable Medical Equipment, Prosthetics, Orthotics and Supplies
By Chris Woolstenhulme, QCC, CMCS, 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 ...
By Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP | Published July 31st, 2014 - Last Review/Update January 25th, 2017
It is a common practice for a solo doctor to find someone to cover for them while they are away from the office for a temporary or extended period of time, such as medical leave, or vacation. Some offices fail to code properly for the services rendered by the “fill-in” ...
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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September 25th, 2019
August 29th, 2019 — ICD-10-CM Changes Effective October 1, 2019
Are you aware of the ICD-10-CM code changes set take effect as of October 1, 2020? Do any of them apply to your organization? Which of them will be assigned as an HCC? What are the documentation and coding guidelines applicable to them and which guidelines are changing or being ...
Success with Out-of-Network Billing in Today's Environment Part 2
In this webinar Maxine will be presenting information and tips for understanding and billing Employment Retirement Income Security Act (ERISA) insurance plans. She will explain the rules and regulations concerning ERISA plans, as well as procedures for handling/appealing "adverse denials" of claims. Coders and Insurance Billing Specialists should not miss this informative presentation.
Success with Out-of-Network Billing in Today's Environment Part 1
In this webinar Maxine will be presenting information and tips for understanding and billing Employment Retirement Income Security Act (ERISA) insurance plans. She will explain the rules and regulations concerning ERISA plans, as well as procedures for handling/appealing "adverse denials" of claims. Coders and Insurance Billing Specialists should not miss this informative presentation.
Total knee replacement now acceptable ASC procedure also, not auditing for a year.
Knee replacement coding, knee joint injections, auditing using FAC, LCDs, drugs, modifiers.
Are you responsible for selecting or reviewing Evaluation and Management service levels? Do you wonder how well you know the rules and how to apply them? Join Aimee in this webinar to review and then applly the rules of E/M coding. She will also do a live demonstration of the new Find-A-Code E/M Calculator Tool to assess the level of E/M service for two office visits, one new (99201-99205) and the other established (99212-99215).
Do you report or audit Telemedicine services now or are you considering offering them? Come and learn more about the rules and guidelines surrounding Telehealth services including, documentation requirements, eligible CPT and HCPCS Level II codes, modifiers, and the newest updates to Medicare Telehealth policies.
Diagnosis coding is difficult when clinician documentation does not match up with the definitions found in the ICD-10-CM code set. Find-A-Code's anatomy images educate both coders and students - bridging the gap between coders and clinicians while simplifying code selection.
FAC Updates Plus Tools for HCC Coding Chart Review February
Join Taylor to see how you can access free CEUs in 3 clicks, included with top-tier Find-A-Code subscriptions! Also highlighting our New and Improved NCDs system, and how to use the WK Drug Database for HCC Coding/Chart Review
Learn How to Optimize Your Subscription, Searching and More
Be more productive, work smarter not harder using Find-A-Code. With so much to offer, it is important to understand how to navigate our site to get the most out of your subscription.
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