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Errors Billing Outpatient Services When Patient is also Inpatient

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E/M Transformations and Clarifications Eff January, 1 2023

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Pay close attention to the new code description changes when coding E/M in 2023, the changes keep coming. Several codes have been consolidated, revised, or deleted. Learn what to look for in this article.

2023 Procedure Coding Updates Are Just Weeks Away

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Even with such a low number of code changes headed our way in 2023, the talk is all about Evaluation and Management (E/M) and speculation about whether our facilities will be able to meet the challenges associated with such a big change. In 2021, when the initial round of E/M changes were announced, they were backed up with a couple of years to prepare for implementation but for facility, it was just months.

Is the Patient Truly Ill? Why Random Audits Could Prevent Recoupment

by  Ronald Hirsch, MD FACP CHCQM CHRI

Three items are discussed in this article: First, performing random audits of critical care visits billed with CPT codes 99291 and 99292 to ensure the patient was truly critically ill, which could help avoid recoupment. Secondly, time will tell if rural hospitals will switch to the rural emergency hospital designation. Lastly, a 2023 OPPS proposed rule, CMS discusses creating a new payment category, paying for software as a service.

Seven Major Changes Proposed by CMS in the 2023 Proposed Rule

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

As the COVID-19-related public health emergency (PHE) seems to be dying down, CMS publishes the 2023 Medicare Proposed Rule that outlines more than a dozen major changes to existing programs, including some that relate to telemedicine after the PHE is declared officially over. Of the many changes, seven (7) really stand out and make us think about how the end of the PHE may affect services such as telemedicine or new E/M encounter types.

More Audits and More Problems

by  Ronald Hirsch, MD FACP CHCQM CHRI

More audits are coming, how do we stay compliant? We have been saying it but now it is happening. More audits are coming your way. One of the two CMS Recovery Audit Contractors seems to have taken on a business expansion plan. It appears they are contacting payers...

Why You Should Be Using The Two-Midnight Rule

by  David M. Glaser, JD

Are you using something other than two-midnight? Here’s why you shouldn’t be. Is there the possibility that your utilization management team and physician advisors are applying InterQual, MCG, or any other utilization tool other than the two-midnight rule to your Medicare admissions? Over the last few months, it has...

2022-06-16-MLNC - ICD-10-CM Diagnosis Codes: Fiscal Year 2023

by  CMS - MLNConnects

News - Comprehensive Error Rate Testing Program Report: Sample Reduced for Reporting Year 2023 - Men’s Health: Talk to Your Patients About Preventive Services - Compliance - Implanted Spinal Neurostimulators: Document Medical Records - Claims, Pricers, & Codes - ICD-10-CM Diagnosis Codes: Fiscal...

Using Health IT to Support Safer Use and Management of Controlled Substance Prescriptions

by  Chelsea Richwine  and  Christian Johnson

New ONC data show that, as of 2021, nearly all non-federal acute care hospitals were enabled to electronically prescribe controlled substances (EPCS). According to the American Hospital Association (AHA) Information Technology (IT) Supplement Survey, the proportion of non-federal acute care hospitals enabled for EPCS increased from 67% in...

The Nuances of the Two-Midnight Rule

by  David M. Glaser, JD

When is a patient an inpatient? A reader we’ll call Michelle asked a question during a recent Monitor Mondays broadcast — a question that encapsulated many of them: how can a Medicare patient who stays two midnights for a non-medical reason be an inpatient?  For example, consider a...

The Conundrum Presented by Outpatient Surgeries

by  Mary Beth Pace, RN BSN MBA ACM CMAC

Do you keep them under inpatient status? Or do you bring them in as outpatients and just keep them overnight?  For our Medicare populations, in all of our organizations, the ability to follow the CPT code of the applicable surgical procedure is the determining factor to bill inpatient...

2022-03-03-MLNC - 2022 Payment, Quality, & Policy Changes

by  CMS - MLNConnects

News - Ambulance Prior Authorization Model Expands April 1 - Nutrition-related Health Conditions: Recommend Medicare Preventive Services - Claims, Pricers, & Codes - HCPCS Application Summaries & Coding Decisions: Drugs and Biologicals - Events - ICD-10 Coordination & Maintenance Committee Meeting — March...

2022-03-10-MLNC - COVID-19 Monoclonal Antibodies: Revised Emergency Use Authorization for EVUSHELD

by  CMS - MLNConnects

News - COVID-19 Monoclonal Antibodies: Revised Emergency Use Authorization for EVUSHELD - Program for Evaluating Payment Patterns Electronic Reports for Short-term Acute Care Hospitals - Quality Payment Program: 2020 Performance Information on Care Compare - Skilled Nursing Facilities: Submit Technical Expert Panel Nominations by March 16 ...

PCS Coding for Ankle Fracture - Look Deeper Into the Codes!

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

If you're looking for ankle fractures in ICD-10-PCS, you may need to look a little deeper. Let's take a look at coding an ankle fracture such as a trimalleolar fracture. PCS coding can be confusing as it is nothing like CPT coding; with CPT we can simply code an ankle ...

IPPS and DRG's: What it Means

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Understanding hospital pricing can get complicated, so we have broken it down according to CMS and the acute Inpatient Prospective Payment System, also known as IPPS. Find-A-Code uses IPPS for inpatient pricing with our MS-DRG grouper. The following information comes from CMS.gov and answers the most common questions regarding DRGs ...

Coding with PCS When There is No Code

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

ICD-10-PCS covers ALMOST everything! But not quite! What if a body system does not contain a body part for toes or fingers? What about an elbow? When it does not cover what you are looking for, where do you turn?  To the guidelines, of course! There are ICD-10-PCS guidelines just as ...

Understanding UCR Inpatient Fees used on DRGs

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

So How Do I Get Paid for This? APC, OPPS, IPPS, DRG?

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

You know how to find a procedure code and you may even know how to do the procedure, but where does the reimbursement come from?  It seems to be a mystery to many of us, so let's clear up some common confusion and review some of the main reimbursement systems.  One of the ...

Type of Bill Code Structure (2018-08-30)

by  Find-A-Code™

The UB-04 claim form (also known as CMS 1450) is the standard facility and residential claim form used to report health claims. The Type of Bill is reported in Block No. 4 of the UB04 claim form. Type of bill codes are four-digit codes that describe the type of bill a ...

Errors Billing Outpatient Services When Patient is also Inpatient

by  Wyn Staheli, Director of Content - innoviHealth

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 ...

Tools and Resources for Life Care Planners

by  Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Life Care Planners play a vital and underappreciated including understanding the progression of a disease and lifetime clinical treatment options, research, delete (I combined this into the paragraph above) compiled into one easy-to-use resource. a unified providing a single destination for procedure coding coding to find information on...
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2023 Annual Update Summary

by  Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Be sure you are ready for 2023 with this review of the upcoming coding and reimbursement updates for 2023. This informative webinar discusses changes to CPT codes and guidelines including a summary of the changes to E/M services and an overview of changes to other CPT categories.

Coding Auditing Inpatient Evaluation and Management — A Hands-On Experience 

by  Find-A-Code™

Do your providers perform and report Evaluation and Management (E/M) services in the inpatient setting? Does the documentation match with the services being billed, or does it fall short? Join Aimee for a hands-on audit of an inpatient E/M service and get an idea of the information and documentation needed to correctly code inpatient E/M services.

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