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Feb 14th, 2024

Information Sharing with the Feds is Risky Business

by David M. Glaser, Esq.

Over the last few weeks, a few articles of mine addressed interacting with government agents. One topic that I did not discuss was determining whether you can, should, or must share information with the government. Unfortunately, it’s not possible to definitively answer that question for every topic, even in...

Jul 14th, 2023

CMS Unveils 2024 Medicare PFS, OPPS Proposed Rules

by Mark Spivey

The OPPS proposal did not feature reference to several high-profile issues industry leaders have been awaiting reform on. Federal officials yesterday unveiled a pair of proposed rules, featuring potential adjustments to the Medicare Physician Fee Schedule (PFS) and Outpatient Prospective Payment System (OPPS) for the 2024 calendar year....

May 30th, 2023

Understanding, Identifying, and Reporting Combination Codes

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

Coders often see conditions that seem to always be reported together. Diabetic patients tend to develop other conditions as the diabetes continues to progress instead of improving. Combination codes are one of those types of codes that identify multiple conditions or diseases but have their own set of special coding guidelines.

May 4th, 2023

What’s Going on with the COVID Vaccines Now?

by Wyn Staheli, Director of Content - innoviHealth

Keeping up with the changes to the COVID vaccines has certainly been a rollercoaster ride and we now have two new twists to this exciting ride. Buckle up and let’s look at how this changes things.

Apr 6th, 2023

Second Quarter 2023 Updates are Different This Year

by Wyn Staheli, Director of Content - innoviHealth

The second quarter of 2023 is NOT business as usual so it is important to pay attention to ensure that organizational processes and training take place to avoid mistakes. Not only have ICD-10-CM coding updates been added to the usual code set updates (e.g., CPT, HCPCS, ICD-10-PCS), but the end of the COVID-19 Public Health Emergency will bring about changes that will also take place during the quarter (but not on April 1, 2023.

Mar 15th, 2023

HCC Re-Structuring Coming Soon!

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Mar 14th, 2023

What is the ICD-10 Code For Dementia?

by Wyn Staheli, Director of Content - innoviHealth

Dementia is a neurocognitive disorder characterized by a meaningful decline in cognition and daily functioning. As of October 1, 2022, there were some significant changes in regards to reporting this condition, so it is important for healthcare professionals to be aware of those changes to ensure that there is proper documentation supporting the ICD-10-CM diagnosis code reported

Feb 27th, 2023

CMS Announces Changes to DME Program

by Wyn Staheli, Director of Content - innoviHealth

CMS recently announced that there have been some changes made to the DMEPOS program. The Medicare Learning Network (MLN) “DMEPOS Quality Standards” lists several changes to the program. Read more about understanding these changes.

Feb 13th, 2023

New Modifier Required on all Single-Use Drugs- JZ and JW Modifiers

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Attention providers and suppliers, there is a new modifier in town! Starting July 1, 2023, Modifier JZ - Zero Drug wasted will be required on all claims to attest there is no drug leftover, If applicable.

Feb 7th, 2023

Is the End Really Near?

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

What happens once the COVID-19 emergency declarations have ended?

Jan 26th, 2023

Relative Value Units (RVUs) the Easy Way, Really?

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

The Medicare Physician fee schedule was implemented in 1992 using a relative Value scale methodology called RVUs to base payment rates on the resources used to perform the service. This is currently how the Medicare Physician Fee Schedule (MPFS) is set. But beware, there may be an industry-wide change to a Value-Based Payment. We will save that for another time; this article will focus on how the RVUs are calculated and Medicare Fee schedules.

Jan 10th, 2023

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.

Dec 20th, 2022

Accurately Reporting Diabetic Medication Use in 2023

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

Along with the ICD-10-CM coding updates, effective as of October 1st, the guidelines were also updated to provide additional information on reporting diabetic medications in both the general diabetic population and pregnant diabetics. Accurate reporting is vital to ensure not only maximum funding for risk adjusted health plans, but also to ensure medical necessity for the services provided to this patient population.

Dec 19th, 2022

REMINDER: CMS Discontinuing the use of CMNs and DIFs- Eff Jan 2023 Claims will be DENIED!

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Updated Article - REMINDER! This is important news for durable medical suppliers! Effective January 1, 2023, CMS is discontinuing the use of Certificates of Medical Necessity (CMNs) and DME information forms (DIFs). We knew this was coming as the MLN sent out an article on May 23, 2022, but it is time to make sure your staff knows about these changes.

Nov 1st, 2022

How Does the Definition of "Problem Assessed" Change in the 2023 E/M Guideline Updates?

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

The 2023 Evaluation and Management changes have been published and efforts are ongoing to educate coders and provider organizations on the guideline and code description changes that will impact professional coding in the facility setting. These changes required a significant revision to the guidelines and definitions of the various levels of complexity associated with the Number and Complexity of "Problems Addressed" during an encounter, which is the first element of medical decision making (MDM) and the following explanations and examples should provide a greater understanding of the changes headed our way in January.

Oct 25th, 2022

Four Ways Your Organization Can Benefit from Gathering and Reporting Social Determinants of Health Data

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

Providers who actively engage in collecting and reporting social determinants of health (SDoH) open avenues of identifying and treating their patients' population health trends. Pairing chronic conditions that are difficult to control with identified SDoH circumstances such as transportation or electricity insecurity, can help identify those patients who may wish to be healthier, but who are dealing with circumstances that prevent compliance, such as transportation or access to electricity, for instance.

Oct 24th, 2022

2023 Evaluation & Management Updates Free Webinar

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

Congratulations on a successful 2021 implementation of the Evaluation and Management (E/M) changes! That was a big change, but now an even bigger change is headed your way for inpatient and all other E/M categories. How great is it that almost all of the E/M categories will now be scored based on medical decision making (MDM) or total provider time? Standardized scoring and one set of E/M guidelines has the potential of bringing about a change or improvement of provider fatigue due to over regulation and documentation burden.

Oct 24th, 2022

End-Stage Renal Disease Risk Model Updates for 2023

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

For the first time, ESRD Medicare beneficiaries were permitted to enroll in Medicare Advantage plans beginning in 2021. Since that time, CMS has been working to revise the program to reduce costs, improve quality, and drive benefits. Effective January 1, 2025, one such change will include a definition change for "oral-only drugs." Why is Medicare changing the definition of these drugs and how will that be a driving force in advancing care models for ESRD in the future?

Oct 24th, 2022

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.

Oct 24th, 2022

Significant Changes to Emergency Department E/M Reporting Coming in 2023

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

In just a few short months, major revisions to the remaining Evaluation and Management categories in the Current Procedural Terminology (CPT) code book will go into effect. How many of these changes will affect your organization and how ready are you for them? While the changes to the remaining E/M categories will closely resemble the 2021 changes to the E/M Office and Other Outpatient (99202-99215) codes, there are some major differences that need to be carefully reviewed, such as how E/M will change for the Emergency Department services.

Oct 6th, 2022

2023 ICD-10-CM Code Changes

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

In 2022 there were 159 new codes; the 2023 ICD-10-CM code update includes 1,176 new, 28 revised, and 287 deleted codes, a substantial change from last year. The 2023 ICD-10-CM codes are to be used for discharges from October 1, 2022 through September 30, 2023, and for patient encounters from ...

Sep 18th, 2022

What is the ICD-10 Code for May-Thurner Syndrome?

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

May-Thurner syndrome is not identified in the Alphabetic Index of the ICD-10-CM codebook, so what is the ICD10 code for reporting this condition? Eponymous diseases are conditions, illnesses, syndromes, disorders, or disease named after the person who either discovered it (usually a physician) or in some cases the patient who was diagnosed with the disease (think Lou Gherig's disease). When trying to identify these diseases in the Alphabetic Index you may have to do a little additional research to identify the actual name of the condition rather than the eponymous name. So what exactly is the ICD-10-CM code for May-Thurner syndrome and what other names does it go by?

Sep 15th, 2022

Emergency Department - APC Reimbursement Method

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

CMS pays emergency department visits through a payment method using Ambulatory Payment Classifications (APCs). Most payers also use the APC reimbursement system; however, there may be some differences in payer policies (always review your specific payer policy). APCs are the primary type of payment made under the OPPS, comprising groupings ...

Aug 21st, 2022

CMS Encourages Medicaid MCOs and CHIP to Employ Section Waivers to Improve SDoH and Reduce Healthcare Costs

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

Over the past few years, at least 15 states have consistently pursued the goal of using social determinants of health (SDOH) in their overall healthcare analysis and treatment programs for patients, and CMS has taken notice. Data and outcomes obtained from these state programs have essentially provided an outline of how the government intends to pursue health equity through managed care contracts (MCOs) and Children's Health Insurance Program (CHIP). What is CMS seeing that they like so much and how might that affect future MCO contracts?

Aug 18th, 2022

CMS says Less Paperwork for DME Suppliers after Jan 2023!

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

This is important news for durable medical suppliers! Effective January 1, 2023, CMS is discontinuing the use of Certificates of Medical Necessity (CMNs) and DME information forms (DIFs). We knew this was coming as the MLN sent out an article on May 23, 2022, but it is time to make sure your staff knows about these changes.

Aug 9th, 2022

How CMS Determines Which Telehealth Services are Risk Adjustable

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

Medicare Advantage Organizations (MAOs) have gone back and forth on whether or not to use data collected from telehealth, virtual Care, and telephone (audio-only) encounters with Medicare beneficiaries for risk adjustment reporting, but the following published documents from CMS cleared that up once and for all by providing an answer to a question specifically related to this question.

Aug 4th, 2022

Billing and Coding: Bone Mass Measurement

by Amanda Ballif

Guidance for billing, coding, and other guidelines in relation to local coverage policy L36460-Bone Mass Measurement.

Jul 21st, 2022

Medicare Advantage and Part D Advance Notice Addresses Health Equity Initiatives Slated for 2023

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

The current Administration constantly talks about health equity initiatives but what exactly does that mean for our providers and medical practices? Centers for Medicare and Medicaid Services (CMS) has published the 2023 Medicare Advantage and Part D Advance Noticed with significant focus on their definition of health equity and what is means to promote it within our individual practices and among health payer plans.

Jul 19th, 2022

The Beginning of the End of COVID-19-Related Emergency Blanket Waivers

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

It appears that the end of the 1135 waivers related to the COVID-19 public health emergency (PHE) has begun. According to CMS, the residents of skilled nursing facilities, long-term care facilities, and inpatient hospice centers have struggled due to the effects of some of the 1135 waivers. CMS is focusing primarily on removing the 1135 blanket waivers that pertain to certain aspects of care, training, and maintenance of these facilities to ensure the weakest of our citizens are guaranteed adequate care.

Jul 14th, 2022

HHS Leaders Urge States to Maximize Efforts to Support Children’s Mental Health

by SAMSHA Newsroom

Today, agencies across the U.S. Department of Health and Human Services (HHS) issued a joint letter to states, tribes, and jurisdictions encouraging them to prioritize and maximize their efforts to strengthen children’s mental health and well-being. The letter, signed by leaders of the Health Resources and Services Administration (HRSA), the Substance Abuse and Mental Health Services Administration (SAMHSA), the Centers for Medicare & Medicaid Services (CMS), the Centers for Disease Control and Prevention (CDC), the Administration for Children and Families (ACF), and the Administration for Community Living (ACL), outlines HHS’ plans to support and facilitate state-level coordination across federal funding streams to advance and expand mental health services for children.

Jul 12th, 2022

E/M Changes Coming Our Way in 2023!

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Changes are one thing we can count on being consistent; even though this is one we have been anticipating, it is time to prepare, and we will have some work to do. The AMA released the new 2023 E/M Guidelines early to help us prepare for the change effective January ...

Mar 31st, 2022

$636 Million in Overpayments Made by Medicare to Providers for Neurostimulators

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

According to the OIG "MEDICARE OVERPAID MORE THAN $636 MILLION FOR NEUROSTIMULATOR IMPLANTATION SURGERIES." So often we think if we get paid, we must be doing it right, well this is not always the case. You may get paid and then have to return the funds if billed incorrectly or a step ...

Mar 21st, 2022

Coding for a Performance of an X-ray Service vs. Counting the Work as a Part of MDM

by Stephanie Allard, CPC CEMA RHIT

When x-rays are audited on the same date as an E/M encounter we have one of three decisions to make about the work that went into the radiological exam when the practice owns x-ray equipment and does their own interpretations internally. First, we must determine whether the x-ray was...

Mar 14th, 2022

Medicare Auditors Caught Double-Dipping

by Edward Roche, PhD JD

Overlapping extrapolations require providers to pay twice. Some Medicare auditors have been caught “double-dipping,” the practice of sampling and extrapolating against the same set of claims. This is like getting two traffic tickets for a single instance of running a red light. This seedy practice doubles the amount...

Mar 10th, 2022

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 ...

Mar 10th, 2022

Cybersecurity & Ransomware Warnings

by Wyn Staheli, Director of Content - innoviHealth

Although HIPAA Security protocols have been in effect for some time, as technology advances, if we are not diligent, gaps can be left available for intruders. On top of that, on February 23, 2022, the American Hospital Association issued a cybersecurity advisory. They stated, “there is concern that Russia may retaliate against the U.S. and allied nations with disruptive cyberattacks.”

Jan 31st, 2022

PDPM Grouper for Skilled Nursing

by Find-A-Code™

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 ...

Nov 11th, 2021

Changes in RPM for 2021! Now, Wait for it... New RTM Codes for 2022

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Remote physiologic monitoring and clinical data monitoring is a relatively new concept thriving and growing as an essential component for telehealth services. According to global consumer trends, a company called Dynata reported, "Among the 39% of people who consulted a healthcare professional, two-thirds used telemedicine, many of them for the first time ...

Oct 28th, 2021

Understanding ASCs and APCs: Indicators and Place of Service

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

The decision regarding the most appropriate care setting for a given surgical procedure is determined by the physician based on the patient's individual clinical needs and preferences. Of course, there is a difference in reimbursement, and the billing depends on where the procedure took place, such as an office setting, inpatient ...

Oct 15th, 2021

Is Your Organization Ready to Deal with Provider Relief Fund (PRF) Audit Contractors?

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

Audits are currently underway to verify the monies distributed through the CARES Act were warranted and properly used by those organizations that received them. The federal government has contracted with financial institutions such as KPMG and PricewaterhouseCoopers, among others, to perform these audits referred to as Provider Relief Fund (PRF) audit contractors, funded with monies from the very same program. There were four phases of funding disbursements with phase 1 audits beginning in September. How ready are you to be audited?

Oct 6th, 2021

ICD-10-CM Cracks Down on the Use of "Unspecified" in the 2021 Official Guidelines

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

We always knew there would come a day when payers would look down on an "unspecified" diagnosis code and possibly even deny it or delay payment until a review of the record could be performed. ICD-10-CM was adopted by the U.S. for data analytics, which cannot be accurate if unspecified codes are reported when the documentation verifies greater specificity. Join us for a look at the many guideline changes to ICD-10-CM, a review of the newest code changes and suggestions on documentation improvement to elevate coding protocols.

Sep 29th, 2021

Injection Services

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Injection Service Codes Injection service codes, are reported under administration of vaccines/toxoids, using 96372, 90460, 90461, 90471, 90472, 0001A, 0002A, 0003A, 0011A, 0012A, 0021A, 0022A, 0031A, 0041A, and 0042A. Other injections services include: Non-antineoplastic hormonal therapy injections – 96372 Anti-neoplastic nonhormonal injection therapy 96401 Anti-neoplastic hormonal injection therapy- 96402 Allergen immunotherapy - 95115-95117 According to CMS, do ...

Aug 4th, 2021

Understanding How Place of Service Codes Work

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

The Place of service (POS) codes are used by CMS, Medicaid, and other private insurance to indicate where medically related items and services are sold or dispensed for a patient. POS codes are used for professional billing and are required to be reported on each claim submitted on a CMS-1500 ...

Jul 29th, 2021

Medicare's ABN Booklet Revised

by Wyn Staheli, Director of Content - innoviHealth

The “Medicare Advance Written Notices of Non-coverage” booklet, published by CMS’s Medicare Learning Network, was updated. This article discusses the changes to this booklet regarding the use of the ABN.

Jul 19th, 2021

Chronic Pain Coding Today & in the Future

by Wyn Staheli, Director of Content - innoviHealth

Properly documenting and coding chronic pain can be challenging. As is commonly the case with many conditions, over the years, there has been a shift in the identification of different types of pain, including chronic pain. Understanding where we are now and where we are going will help your organization prepare for the future by changing documentation patterns now.

Jul 14th, 2021

How to Properly Assign ICD-10-CM Codes for Pain

by Wyn Staheli, Director of Content - innoviHealth

Pain is a common diagnosis among all specialties so it should not be surprising to find there are 162 ICD-10-CM codes for reporting it and over 80 mentions in the ICD-10-CM Official Guidelines for Coding and Reporting which describe when certain types of pain should be reported and how the codes should be sequenced.

Jun 29th, 2021

Compliance in the Small Practice

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

If your practice does not already have a compliance program in place, you will want to get started after reading this article. We have uncovered some important findings with the Office of Inspector General (OIG) in dental practices you need to be aware of. A compliance program offers standard procedures to follow, ...

Jun 23rd, 2021

UCR Anesthesia Fee Calculations and Base Units - Now Available!

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

As per customer request, Find-A-Code now offers UCR Anesthesia Fee Calculations along with CMS and ASA. The anesthesia fee calculations can be found under the Fees section of the code and under the Anesthesia Fee Information. Time units are computed by dividing the reported anesthesia time by 15 minutes (17 minutes / 15 minutes = 1.13 units). NOTE: Always ...

Jun 3rd, 2021

Understanding Non-face-to-face Prolonged Services (99358-99359) in 2021

by Wyn Staheli, Director of Content - innoviHealth and Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Due to the extensive changes in office or other outpatient services (99202-99215), there are many questions which still need to be answered, one of which is related to the prolonged services without face-to-face contact. This article explores the question regarding the appropriate use of codes 99358/99359 and how to report it.

Apr 27th, 2021

Why Will Medicare Administrative Contractors be Holding Claims Up?

by Jared Staheli, MPP

When Congress passed the expansive American Rescue Plan Act last month, most Americans were focused on the direct payment provision of the bill. However healthcare administrators and policymakers had their attention on another aspect: cuts to Medicare payments. Why would Congress be cutting Medicare payments during the COVID-19 Public Health ...

Apr 20th, 2021

ICD-11 — What’s Happening?

by Wyn Staheli, Director of Content - innoviHealth

ICD-11 is officially released, but what does that mean for diagnosis coding in the United States? What's really different? This article discusses what has been happening with ICD-11, some interesting things to note about it, as well as links to other important information.

Apr 19th, 2021

Q/A: For E/M, How do I Count Tests Ordered in One Department and Performed in Another?

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

Question: I am in an ENT office as part of a large clinic with separate practices including audiology, CT, and allergy, all billing under the same TAX ID. Sometimes tests are ordered which are done in other departments that my office does not bill for, would those be considered an outside source? Answer: This is a great question and one that has been asked by many coders and auditors.

Apr 1st, 2021

Evaluation & Management (E/M) Webinar Q/A

by Wyn Staheli, Director of Content - innoviHealth and Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Find answers to some questions asked by attendees of our recent webinar regarding the changes released by the AMA in their March 9, 2021 Errata and Technical Corrections document in relation to Evaluation & Management (E/M).

Mar 18th, 2021

How Reporting E/M Based on Time May Lose Money

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

Just like math teachers who require students to show their work so they can see how the student reached their answer, providers are also required to "show their work" through the documentation process in the medical record. By the time a provider has reviewed the patient's subjective complaints (i.e., patient's ...

Mar 16th, 2021

Critical Evaluation and Management Changes Recently Announced by AMA

by Wyn Staheli, Director of Content - innoviHealth

On March 9, 2021, the American Medical Association (AMA) announced some pretty significant changes in relation to reporting Evaluation and Management (E/M) services, particularly for Office or Other Outpatient Services (99202-99215). The AMA Editorial Panel had previously met to discuss how to address concerns and made changes surrounding Office or Other Outpatient Services which are retroactive to January 1, 2021. Learn more about those changes in this article.

Feb 22nd, 2021

COVID Vaccinations — FREE Legal and Ethical Considerations Webinar

by Wyn Staheli, Director of Content - innoviHealth

Learn about legal and ethical implications of the COVID-19 vaccine with this free webinar held on Wednesday, February, 24, 2021.

Feb 17th, 2021

Why CMS Created G2212 for Prolonged Services Instead of 99417

by Wyn Staheli, Director of Content - innoviHealth

This article discusses WHY CMS decided to create code G2212 to be used with prolonged office Evaluation and Management (E/M) services instead of code 99417 as of January 1, 2021. The proposed Medicare Physician Fee Schedule stated that code 99417 would be used so it is essential to understand why they made this change to avoid potential problems with billing these services.

Feb 3rd, 2021

How To Properly Report Prolonged Services Using 99417 or G2212

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

Prolonged Evaluation & Management codes underwent big changes in 2021, including the creation of a new prolonged code (99417), reportable only with codes 99205 or 99215. While Medicare has agreed to accept the AMA's CPT E/M coding changes, they have formulated an opinion contrary to how CPT calculates time specific ...

Jan 11th, 2021

HIPAA Penalty Changes

by Wyn Staheli, Director of Content - innoviHealth

On January 5, 2021, H.R. 7898 was signed into law by President Trump. This new law modifies the HITECH Act such that when an organization experiences a breach, fines and/or penalties may be reduced if (for at least a year) they have instituted “recognized security practices” as defined within the law.

Oct 12th, 2020

What is the Difference Between the Medicare 1995 and 1997 Documentation Guidelines for E/M Services?

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

When Medicare determined that providers could follow EITHER the 1995 OR the 1997 Documentation Guidelines for Evaluation and Management Services to determine which level of E/M service to report, because CMS had not clarified that portions of the 1995 and 1997 guidelines could be used together to determine the level of ...

Aug 24th, 2020

2021 Brings Another Risk Adjustment Calculation Change

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

In 2021, a big change in Risk Adjustment score calculations will take place, which will affect payments to Medicare Advantage (MA) plans for the coming year and take us closer to quality and value-based programs instead of fee-for-service (FFS) or risk-adjusted (RA). Currently, CMS pays a per-enrollee capitated...

Aug 10th, 2020

Coding Injections for Pain Management

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Coding for pain management can get confusing. How many injections, the location, and when to use a modifier are all common questions. This article will cover some of the most common injections used in pain management. Trigger Point Injections Trigger point injections are reported by how many muscles are treated using an ...

Aug 10th, 2020

Modifier 50 — Four "Must Know" Tips For Getting Paid

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

Modifiers added to an HCPCS or CPT© code alters the code description, providing clarity about the service for proper claim processing and reimbursement. Here are four things you must know about modifier 50 to ensure proper payment. - Modifiers are either informational or payment related. Informational modifiers provide additional...

Aug 5th, 2020

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 ...

Jul 14th, 2020

Are NCCI Edits and Modifiers Just for Medicare?

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Jul 1st, 2020

Understanding UCR Inpatient Fees Used on DRGs

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Jun 15th, 2020

Outpatient Facility Pricing

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Our newest feature launch offers UCR pricing for Outpatient Facility. We recently released pricing information based on databases of insurance claims from private-sector health care providers.Usual, customary, and reasonable charges (UCR) are medical fees used when there are no contractual pricing agreements and are used by certain healthcare plans and third-party payers to generate ...

Jun 10th, 2020

MEGA - NCCI Edit Changes - WHO Knew?

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

There was no huge announcement when CMS released new files in April. The files that were released on April 7, 2020, actually replaced files to update the NCCI edits on Procedure to Procedure (PTP) edits and Medically Unlikely Edits (MUE). The updated files included; 291,902 Deleted Procedure to Procedure (PTP) edits 197 Deleted Medically Unlikely ...

May 13th, 2020

Are Diagnoses from Telehealth Services Eligible for Risk Adjustment?

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

On April 10th, CMS released a memo with the subject line, “Applicability of diagnoses from telehealth services for risk adjustment,” suggesting there may be some telehealth services that might not qualify for risk adjustment. However, in the memo CMS states: “Diagnoses resulting from telehealth services can meet the risk adjustment face-to-face ...

May 5th, 2020

ICD-10-CM - Supplement information for E-Cigarette/Vaping Reporting

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

The CDC has released additional information and coding guidance for reporting encounters related to the 2019 health care encounters and deaths related to e-cigarette, or vaping, product use associated lung injury (EVALI). The update offers coding scenarios for general guidance, poisoning and toxicity, substance abuse and signs and symptoms. ICD-10-CM Official Coding Guidelines - ...

May 4th, 2020

Additional Telehealth Changes Announced by CMS

by Wyn Staheli, Director of Content - innoviHealth

On April 30, 2020, CMS announced additional sweeping changes to meet the challenges of providing adequate healthcare during this pandemic. These changes expand the March 31st changes. The article covers some of the key changes. See the official announcement in the references below.

Apr 20th, 2020

Clarify the Complexity Please! NDC Codes and Drug Classification Systems

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Different Drug classification systems are used to categorize drugs to identify the medication, with each system having their own logic. There are four main drug classification systems used in the United States, not to be confused with a class of drugs or "Drug Class". A drug class is the way drugs ...

Apr 20th, 2020

Dismal OIG Report on Telemedicine

by Wyn Staheli, Director of Content - innoviHealth

Providers need to understand the rules for reporting telemedicine services. A recent OIG report shows that this is not the case. What problems are being found in documentation claims? As providers are expanding their telehealth offerings, now is the time to understand the potential pitfalls since disallowed amounts will be taken back.

Apr 16th, 2020

Hypertension ICD-10-CM Coding Table, Guidelines, and Tips

by Wyn Staheli, Director of Content - innoviHealth and Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT

Coding hypertension properly requires knowing all the guidelines. This article summarizes how hypertension is coded using ICD-10-CM and includes tips, definitions and a very helpful coding table summarizing your options.

Apr 15th, 2020

CMS Temporarily Suspends Contract-Level RADV Audits

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

The Centers for Medicare and Medicaid Services (CMS) is suspending contract-level RADV audits, related to the payment year 2015 and will not initiate any new ones until after the public health emergency has ended. Any documentation already submitted will be reviewed as usual.

Apr 15th, 2020

New CPT® Codes Approved for COVID-19 Antibody Identification

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

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.

Apr 13th, 2020

CMS Announces Final 2021 HCC Risk Adjustment Changes

by Wyn Staheli, Director of Content - innoviHealth

On April 6, 2020, the Centers for Medicare & Medicaid Services (CMS) published their final Medicare Advantage (MA) and Part D payment methodologies for CY 2021. Read more to be prepared for these upcoming changes.

Apr 13th, 2020

Financial Impact of CARES Act on Healthcare Providers

by Wyn Staheli, Director of Content - innoviHealth

The recently enacted Coronavirus Aid, Relief, and Economic Security (CARES) Act has several provisions to ease the financial burden being faced by healthcare providers who have been impacted by the effect of the coronavirus. Learn more about how the Provider Relief Fund and the Accelerated and Advance Payment Program work.

Apr 1st, 2020

External Cause Status Coding (Y99)

by Wyn Staheli, Director of Content - innoviHealth

This innoviHealth book (i.e., ICD-10-CM Coding, Reimbursement Guide) resource discusses requirements for properly coding external causes. Mandatory reporting of these codes is not always required by all payers and even when they are required, it might only be in certain situations (e.g., drug overdose, personal injury).

Mar 31st, 2020

CMS-Coverage for Therapeutic Shoes for Individuals with Diabetes

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Mar 24th, 2020

"What is the ICD-10 code for...?" - Search Smarter With Find-A-Code Tools

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

Do you still find yourself searching the internet for an ICD10 code? Medical coders often type into their search engine, what is the ICD10 code for ... and a specific diagnosis code, to avoid repeatedly dragging out the incredibly large ICD10 codebook. Ironically, some of the most commonly searched ICD10 diagnoses include: ...

Mar 21st, 2020

Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)

by Aubrie Rowley

The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...

Mar 5th, 2020

Who Qualifies for Chronic Care Management Services

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Feb 20th, 2020

New HCPCS Code for Coronavirus Testing Announced

by Wyn Staheli, Director of Content - innoviHealth

Currently, healthcare providers testing patients for Coronavirus must use an unspecified code. To provide better tracking, on February 13, 2020, CMS announced the creation of a new HCPCS code.

Jan 21st, 2020

Inadequate Exclusion Screenings Could Put Your Practice at Risk

by Wyn Staheli, Director of Content - innoviHealth

Exclusion screenings require far more than just checking a name on a federal database at the time you are hiring someone. Far too many providers don’t realize that in order to meet compliance requirements, there is MUCH more involved. There are actually over 40 exclusion screening databases/lists that need to be checked.

Dec 30th, 2019

Medicare Changes Bilateral Reporting Rules for Certain Supplies

by Wyn Staheli, Director of Content - innoviHealth

DME suppliers must bill bilateral supplies with modifiers RT and LT on separate claim lines or they are being rejected.

Dec 19th, 2019

CMS- Patient Driven Payment Model Effective October 01, 2019

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

According to CMS, In July 2018, CMS finalized a new case-mix classification model, the Patient-Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay. Using the new Patient-Driven ...

Dec 9th, 2019

CMS says Codes are on the Move!

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Nov 25th, 2019

Hypertension ICD-10-CM Code Reporting Table

by Wyn Staheli, Director of Content - innoviHealth

In ICD-10-CM, hypertension code options do not distinguish between malignant and benign or between controlled and uncontrolled. What is important for code selection is knowing if the hypertension is caused by or related to another condition. The following table shows some of these options.

Nov 12th, 2019

HIPAA Final Rule Eliminates HPID and OEID

by Wyn Staheli, Director of Content - innoviHealth

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.

Nov 11th, 2019

And Then There Were Fees...

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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...

Oct 21st, 2019

VA- Reasonable Charges Rules, Notices, & Federal Register

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Oct 7th, 2019

Hypertension & ICD-10

by Raquel Shumway

Hypertensive Diseases and ICD-10. Helps and examples for these codes.

Oct 1st, 2019

2020 Official ICD-10-CM Coding Guideline Changes Are Here!

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Oct 1st, 2019

Do ICD-10 Updates Have Your Heart Beating Irregularly? Check Out the New Atrial Fibrillation Codes

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

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 ...

Sep 30th, 2019

CMS and HHS Tighten Enrollment Rules and Increase Penalties

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Aug 20th, 2019

Are You Aware of Medicare Advantage Plans Timely Filing Rules?

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

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 ...

Aug 16th, 2019

Medical ID Theft

by NAMAS

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. ...

Aug 13th, 2019

How to Properly Report Prolonged Evaluation and Management Services

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

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 ...

Aug 9th, 2019

The OIG Work Plan: What Is It and Why Should I Care?

by NAMAS

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 ...

Jul 26th, 2019

Anthem is Changing their Timely Filing Requirements for All Plans, Including Medicare Advantage

by NAMAS

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 ...

Jul 22nd, 2019

Are These Problems Hurting Your Practice?

by Wyn Staheli, Director of Content - innoviHealth

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.

Jul 19th, 2019

The Facts of Critical Care

by NAMAS

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 ...

Jul 12th, 2019

5 Ways to Minimize HIPAA Liabilities

by BC Advantage

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 ...

Jul 5th, 2019

Helping Others Understand How to Apply Incident to Guidelines

by NAMAS

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 ...

Jun 27th, 2019

2018 Medicare Improper Payment Report Shows Slight Improvement but There's Still Work to be Done

by Wyn Staheli, Director of Content - innoviHealth

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. ...

Jun 21st, 2019

Small Breaches Can Be Subject to Large Penalties

by NAMAS

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 ...

Jun 18th, 2019

How to Properly Report Monitoring Patients Taking Blood-thinning Medications

by Wyn Staheli, Director of Content - innoviHealth

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.

Jun 17th, 2019

Extrapolation Policies Apply to RAD-V Audits

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

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 ...

Jun 14th, 2019

A United Approach

by NAMAS

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 ...

Jun 13th, 2019

What Medical Necessity Tools Does Find-A-Code Offer?

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

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 ...

Jun 6th, 2019

How to Code Ophthalmologic Services Accurately

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

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 ...

May 29th, 2019

Noting "Noncontributory" for Past Medical, Family, Social History - Is It Acceptable?

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

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?

May 21st, 2019

RT and LT Modifier Usage Change (effective 2019-03-01)

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Apr 29th, 2019

Medicare Revises Their Appeals Process

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Apr 26th, 2019

Medicare Revises Their Appeals Process

by Wyn Staheli, Director of Content - innoviHealth

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.

Apr 23rd, 2019

Let's Talk High Risk E/M Services

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

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 ...

Apr 23rd, 2019

What is Medical Necessity and How Does Documentation Support It?

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

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 ...

Apr 8th, 2019

Prepayment Review Battle Plan

by Wyn Staheli, Director of Content - innoviHealth

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. ...

Apr 1st, 2019

Q/A: Can I Tell a Medicare Patient Which Option to Check on the ABN?

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Apr 1st, 2019

Spinal Cord Stimulator Used for Chronic Pain

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Chronic pain is a condition that can be diagnosed on its own or diagnosed as a part of another condition. When coding chronic pain, there is no time frame defining when pain becomes chronic pain; the provider’s documentation should be used to guide the use of these codes. ICD-10-CM Diagnosis Codes ...

Mar 27th, 2019

Pain Codes in ICD-10-CM

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Mar 25th, 2019

Clearing Up Some Medicare Participation Misunderstandings

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Mar 22nd, 2019

Q/A: How do we Know Which Codes a Payer Will Allow?

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Mar 21st, 2019

The Impact of Medical Necessity on High Level E/M Services

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

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. ...

Mar 18th, 2019

How to Report Imaging (X-Rays) of the Thumb

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

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 ...

Mar 7th, 2019

Q/A: Can you Help me Understand the New Medicare Insurance Cards?

by Wyn Staheli, Director of Content - innoviHealth

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.

Mar 4th, 2019

UnitedHealthcare to Discontinue Coverage of Consultations

by Wyn Staheli, Director of Content - innoviHealth

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).

Mar 1st, 2019

Understanding NCCI Edits

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

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 ...

Feb 14th, 2019

Proposed Rule: Expanded Telemedicine Benefits for Medicare Advantage Beneficiaries

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

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 ...

Feb 12th, 2019

Coding Medicare Initial Preventive Physical Exams (IPPE)

by Aubrie Rowley

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 ...

Feb 7th, 2019

Q/A: Do Digital X-rays Have Their Own Codes?

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Feb 5th, 2019

Clinical Staff vs. Healthcare Professional

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

State scope of practice laws and regulations will help determine who is considered Clinical staff and Other qualified Health Care professionals. Physician or other qualified healthcare professionals: Must have a State license, education training showing qualifications as well as facility privileges. Examples of Qualified Healthcare professionals: (NOTE: this list is not all-inclusive, please refer to your payer ...

Feb 1st, 2019

Attestations Teaching Physicians vs Split Shared Visits

by BC Advantage

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 ...

Jan 28th, 2019

Empowering Medicare Beneficiaries

by Find-A-Code™

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 ...

Jan 25th, 2019

Medical Necessity vs. Documentation for Inpatient Services

by NAMAS

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 ...

Jan 23rd, 2019

Everything You need to Know about Drugs

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Jan 23rd, 2019

How to Report Co-Surgeons Using Modifier 62

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

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 ...

Jan 3rd, 2019

CMS Finalizes Major Changes to ACO Program

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Jan 3rd, 2019

Dry Needling

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Nov 29th, 2018

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 ...

Nov 28th, 2018

Q/A: Do Croft Guidelines Apply After Time has Passed Since the Accident?

by Tom Grant DC, Med-Legal Consultant, Pragma Intel Director of Education

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?

Nov 26th, 2018

Reciprocal Billing and Locum Tenens Arrangements Changes

by Wyn Staheli, Director of Content - innoviHealth

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.

Oct 17th, 2018

Wolters Kluwer Drug Pricing

by Find-A-Code™

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...

Oct 16th, 2018

Q/A: What Codes do I use for CLIA-Waived Tests?

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Oct 2nd, 2018

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...

Sep 12th, 2018

Join QPro Today and Get Certified

by Find-A-Code™

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 ...

Aug 31st, 2018

Finalized Confidentiality of Alcohol and Drug Abuse Patient Records Regulations

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Aug 20th, 2018

PSAVE Pilot Program - What Does it Mean to You?

by Wyn Staheli, Director of Content - innoviHealth

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?

Aug 16th, 2018

Medicare Timed Codes Guidelines

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Aug 16th, 2018

Using Modifiers 96 and 97

by Wyn Staheli, Director of Content - innoviHealth

The Affordable Care Act (ACA) requires coverage of certain essential health benefits (EHBs), two of which are rehabilitative and habilitative services and devices. Since the ACA did not define these terms or specify coverage requirements, it is left up to individual states to create benchmark plans to determine coverage requirements. ...

Jul 12th, 2018

Dual Medicare-Medicaid Billing Problems

by Wyn Staheli, Director of Content - innoviHealth

It is important to keep in mind that Medicaid is run at a state level so there can be some differences when it comes to coverage. However, the rules regarding balance billing of covered services is set at the federal level. The law states (emphasis added): A state plan must provide ...

Jul 12th, 2018

Q/A: Can You Swap Out 97140 with 97530?

by Wyn Staheli, Director of Content - innoviHealth

Codes 97140 and 97530 are not interchangeable. See why.

Jul 9th, 2018

Documentation: Face to Face for Home Health Certification

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Jun 22nd, 2018

Q/A: Do I Have a Patient with Part C sign an ABN if we are Out-of-Network?

by Wyn Staheli, Director of Content - innoviHealth

Do we need an ABN if the patient has Part C and we are out-of-network? Read More.

Jun 14th, 2018

VA Expands Telehealth

by Wyn Staheli, Director of Content - innoviHealth

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 ...

May 22nd, 2018

Q/A: Am I Supposed to List the Frequency and Duration on the ABN?

by Wyn Staheli, Director of Content - innoviHealth

How to fill out Box D (Services) on the ABN form. What information is required?

May 9th, 2018

Preventive Medicine: Diabetes Self-Management Training

by Find-A-Code™

Preventive Medicine Topics Page Diabetes Self-Management Training Procedure Codes G0108: DSMT, individual, per 30 minutes G0109: GDSMT, group (2 or more), per 30 minutes ICD-10-CM G0108-G0109: Contact payer for more specific guidelines Frequency G0108-G0109 Initial year: Up to 10 hours of initial training within a continuous 12-month period Subsequent years: Up to 2 ...

Apr 23rd, 2018

Q/A: Someone Broke into My Office. What do I do Now?

by Wyn Staheli, Director of Content - innoviHealth

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?

Apr 12th, 2018

Billing Nutrition Counseling

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Mar 29th, 2018

Medicare Telemedicine Changes for 2018

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

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 ...

Mar 13th, 2018

CPT Code for DOT exams

by Wyn Staheli, Director of Content - innoviHealth

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?

Mar 8th, 2018

Documentation and Orders for Laboratory Tests

by Medicare Learning Network

The Medicare Learning Network provides guidance on required documentation for ordering laboratory tests.

Mar 8th, 2018

Documentation for Home Blood Glucose Monitors (BGM)

by Medicare Learning Network

The Medicare Learning Network provides guidance on how to Prevent Denials for Home Blood Glucose Monitors (BGM)...

Mar 8th, 2018

Documentation for Home Health Services (Part A non DRG)

by Medicare Learning Network

The Medical Learning Network provides coverage guidance, which should be documented, for home health services.

Mar 1st, 2018

New Bipartisian Budget Act of 2018 Provisions

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Feb 28th, 2018

Telemedicine Billing and Reimbursement

by Jared Staheli, MPP

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 ...

Feb 21st, 2018

No HCPCS Code Available? Now What?

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Feb 5th, 2018

HIPAA Breach Settlements and Ransomware Attacks - Is Your Practice Secure?

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Feb 1st, 2018

Multiple Diagnostic Imaging Payment Reduction

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Feb 1st, 2018

OIG Reviews Medicare Advantage Claims

by Wyn Staheli, Director of Content - innoviHealth

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; ...

Jan 29th, 2018

Anesthesia and Fee Calculation

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Fees for anesthesia services are not calculated the same as for other types of procedures. There are four elements to consider when calculating anesthesia fees. Medicare accepts base units and time units; however, depending on the third-party payer, they may or may not accept physical status units and/or qualifying circumstances units. Base Unit (of the CPT code) Time (in ...

Jan 24th, 2018

HIPAA and the Opioid Crisis

by Wyn Staheli, Director of Content - innoviHealth

HIPAA and the Opioid Crisis guidance released by HHS.

Jan 16th, 2018

Patient Relationship Codes

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Jan 11th, 2018

Advance Beneficiary Notice of Noncoverage (ABN) Modifier Guidelines

by Find-A-Code™

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 ...

Jan 4th, 2018

Billing Negative Pressure Wound Therapy (NPWT) (disposable device)

by Find-A-Code™

Per CMS: Disposable NPWT services are billed using the following Current Procedural Terminology® (CPT®) codes: 97607 - Negative pressure wound therapy, (e.g., vacuum assisted drainage collection), utilizing disposable, non-durable medical equipment including provision of exudate management collection system, topical application(s), wound assessment, and instructions for ongoing care, per session; total wound(s) surface area less than or ...

Jan 4th, 2018

Special Skilled Nursing Facility (SNF) Billing Exceptions for Laboratory Tests PUB-100 40.4

by Find-A-Code™

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 ...

Jan 3rd, 2018

Abuse, Neglect, or Maltreatment

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Dec 28th, 2017

DME Documentation Requirements

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Dec 8th, 2017

Quality Reporting and Payment Reduction

by ChiroCode™

Checking my NPI number on the CMS site.

Dec 4th, 2017

Revised ABN and Non-Participating Providers

by Wyn Staheli, Director of Content - innoviHealth

Non-participating providers have the option to strikeout part of the ABN form.

Nov 30th, 2017

Coding Carpal Tunnel Syndrome

by Wyn Staheli, Director of Content - innoviHealth

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?

Oct 31st, 2017

Modifier NU

by Brandy Brimhall, CPC CMCO CPCO CCCPC CPMA QCC

Is it necessary to use the modifier NU for all supplies? or is NU part of the code itself? Where should the NU be noted on the 1500 form?

Oct 13th, 2017

So, How Do You Decide if a Service was Provided?

by David M. Glaser, JD

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.....

Sep 29th, 2017

Stark Law for Healthcare Providers

by Brandy Brimhall, CPC CMCO CPCO CCCPC CPMA QCC

Be aware of physician self-referral laws and how they affect your practice.

Sep 14th, 2017

Double Dipping in the History of the Evaluation and Management Note

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

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 ...

Sep 1st, 2017

Preventive Services: Diabetes Self-Management Training (DSMT)

by Find-A-Code™

The following information from the Medicare Learning Network provides guidance on Diabetes Self-Management Training....

Sep 1st, 2017

Preventive Services: Hepatitis C Virus (HCV) Screening

by Find-A-Code™

The following information from the Medicare Learning Network provides guidance on Hepatitis C Virus (HCV) Screening....

Aug 29th, 2017

Elderly Abuse Discovered by the OIG - Early Alert

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

The OIG sent out an early alert in an effort to create awareness to potential abuse or neglect of Medicare Beneficiaries in skilled nursing facilities. The OIG identified 134 Medicare beneficiaries whose injuries may have been the result of potential abuse or neglect. The beneficiaries reported were treated at the ...

Aug 4th, 2017

Proposed Telehealth Changes for 2018

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Aug 4th, 2017

Veterans Choice Program

by Wyn Staheli, Director of Content - innoviHealth

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.

Aug 1st, 2017

Annual Wellness Visit (AWV)

by Wyn Staheli, Director of Content - innoviHealth

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.

Aug 1st, 2017

HIPAA Training Requirements

by Wyn Staheli, Director of Content - innoviHealth

HIPAA Training must be an ongoing effort in every healthcare organization.

Jul 28th, 2017

Auditing Vaccines

by Paul Chandler

Auditing vaccines can be difficult, as precise attention needs to be paid to the documentation to extract all variables needed for proper coding.

Apr 10th, 2017

False Claim Penalties Increase Again

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Mar 2nd, 2017

Principal Diagnosis

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Mar 2nd, 2017

Using Modifier EY

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Feb 27th, 2017

How to Properly Dispose Protected Health Information (PHI)

by InstaCode Institute

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 ...

Feb 23rd, 2017

Physician Compensation Fraud Alert

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Feb 22nd, 2017

Global Periods

by Wyn Staheli, Director of Content - innoviHealth

What are the types of global periods?

Feb 8th, 2017

Medicare Conversion Factor

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Feb 6th, 2017

Medicaid EHR Incentive

by Wyn Staheli, Director of Content - innoviHealth

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. ...

Feb 6th, 2017

Medicare Revises their Appeals Process

by Wyn Staheli, Director of Content - innoviHealth

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. ...

Jan 24th, 2017

Code Sets - Health Care Provider Taxonomy Code Set Link

by Raquel Shumway

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.

Jan 16th, 2017

Alternative Payment Models (APMs) and Advanced APMs

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Dec 20th, 2016

ABN FAQs

by Wyn Staheli, Director of Content - innoviHealth

This handy FAQ addresses the uses and mis-uses of the ABN form.

Dec 13th, 2016

Health Risk Assessment

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Dec 12th, 2016

60 Day Final Rule

by Wyn Staheli, Director of Content - innoviHealth

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.

Dec 7th, 2016

Discounts

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Nov 28th, 2016

Product Wastage Documentation Requirements and Reporting: Using JW Modifier

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Sep 17th, 2016

Government Healthcare Programs

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Aug 3rd, 2016

Billing Units

by Wyn Staheli, Director of Content - innoviHealth

Are you billing units correctly? This article outlines important considerations to ensure that claims are submitted properly.

Jun 21st, 2016

Voluntary Overpayments

by Wyn Staheli, Director of Content - innoviHealth

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.

Jun 9th, 2016

Mandatory Submission of Staffing Data via PBJ Begins July 1 for Long – Term care facilities

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Electronic submission of staffing data through the Payroll-Based Journal (PBJ) is required of all long-term care facilities starting July 1. The last day to submit data for fiscal quarter four (July 1 through September 30) is November 14, 2016. Nursing homes can register now in the PBJ system to prepare: Obtain ...

Jun 9th, 2016

Understanding and Using Taxonomy Codes to Maximize Reimbursement

by Brittney Murdock, QCC CMCS CPC

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 ...

May 19th, 2016

Skilled nursing facilities paid for participating in new program, starting the summer of 2016

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Medicare plans to start a Skilled Nursing Facility Value-Based Purchasing Program (SNFVBP), beginning fiscal year 2019. This program will be used to promote better clinical outcomes for skilled nursing facility patients and improve care during their stay at a skilled nursing facility. Skilled nursing facilities will be paid for participating. ...

Apr 13th, 2016

Telehealth Basics

by Wyn Staheli, Director of Content - innoviHealth

Telehealth and telemedicine are covered for many payers for services such as consultation, office visits, individual psychotherapy, and pharmacologic management delivered via a telecommunications system.

Mar 4th, 2016

What is an 'Other Qualified Healthcare Professional'?

by Wyn Staheli, Director of Content - innoviHealth

What's the difference between a physician, an other qualified healthcare professional, clinical staff and individual.

Feb 24th, 2016

Employee Exclusions Screenings Must be High Priority

by Wyn Staheli, Director of Content - innoviHealth

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.

Feb 1st, 2016

Will Incident-To in Your Organization Pass a Compliance Audit?

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

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.

Sep 11th, 2015

Essential Health Benefits (EHBs)

by Wyn Staheli, Director of Content - innoviHealth

Information about the mandated Essential Health Benefits (EHBs). Includes links and other helpful information.

Aug 3rd, 2015

Notice of Election (NOE) - Form CMS - 1450 (Rev. 3118)

by Find-A-Code™

When a Medicare beneficiary elects hospice services, hospices must complete form locators identified in section 20.1.2 for the Uniform (Institutional Provider) Bill (Form CMS-1450), which is an election notice. In addition, the hospice must complete the Form CMS-1450 when the election is for a patient who has changed an election from one ...

May 11th, 2015

Modifier 33

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

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 ...

May 7th, 2015

Personal Injury Information by Find-A-Code

by Find-A-Code™

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.

Mar 17th, 2015

Patient Information Form

by Raquel Shumway

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 ...

Feb 10th, 2015

MAC Jurisdictions Resources

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Feb 3rd, 2015

Health Care Reform

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Dec 4th, 2014

Correct Coding: Braces (Orthoses) Attached to Wheelchairs

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

Joint DME MAC and PDAC Publication Recently, claims for braces attached to wheelchairs have been submitted using HCPCS code K0108 - WHEELCHAIR COMPONENT OR ACCESSORY, NOT OTHERWISE SPECIFIED. K0108 is not the correct HCPCS code to use for these items. CMS has clarified the distinction between braces (orthoses) and durable medical equipment (DME) under Medicare Part ...

Nov 5th, 2014

Is Modifier -59 going away?

by Jared Staheli, MPP

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.”

The new codes are:

Sep 15th, 2014

Medicare Definition of Timed Codes

by Wyn Staheli, Director of Content - innoviHealth

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.

Sep 9th, 2014

Compliance Specialists

by Jared Staheli, MPP

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, ...

Aug 26th, 2014

Q & A: What is the Definition of "New Patient" for Billing Evaluation and Management (E/M) Services?

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

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 ...

Aug 13th, 2014

Consolidated Billing (CB) for SNF (Skilled Nursing Facilities) - Exceptions

by Christine Woolstenhulme, QMC QCC CMCS CPC CMRS

SNF itself must submit all Medicare claims for the services that its residents receive (except for specifically excluded services listed below). CB for SNF resembles the bundling requirement for Inpatient Hospital Services, assigning the facility responsible for the entire package except for certain services that are specifically excluded. Physicians' services furnished to ...

Jan 1st, 2014

Testing & Screening Tools

by Wyn Staheli, Director of Content - innoviHealth

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 ...

Nov 30th, -0001

2022-11-23-MLNC - Weekly Edition

Colorectal Cancer Screening Test: Reduced Coinsurance for Related Procedures Begins January 1 - - Ambulance Fee Schedule: CY 2023 Inflation Factor & Productivity Adjustment - - Medicare Ground Ambulance Data Collection System: Information to Help You Report - -...

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Mar 9th, 2023

Keeping up to date on reporting changes...

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

Properly reporting split or shared patient encounters can be tricky. The CPT codebook just began defining this type of encounter and the 2023 Medicare Physician Fee Schedule Final Rule included some changes. Tune into this informative webinar to ensure that you are doing things the right way.

Jun 2nd, 2022

Coding 2022 Care Management Services

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

Jan 7th, 2020

Rock Solid Care Plans

by Evan M. Gwilliam, DC MBA CPC CCPC CPC-I QCC MCS-P CPMA CMHP AAPC Fellow

Don't ever let anyone challenge your care plans ever again. If you can know what the regulators are looking for while still being free to deliver the care you deem to be best for your patient, then you win. And your patient wins. Join Dr. Gwilliam, certified professional medical auditor, and all around nice guy, as he guides you to the steps to create rock solid care plans that will stand up to third party scrutiny.

Aug 29th, 2019

ICD-10-CM Changes Effective October 1, 2019

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

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 ...

Jun 17th, 2019

Telehealth Policies for Medicare and Commercial Payers

Feb 21st, 2019

E/M and the Organ Systems Part 2 of 2

Feb 7th, 2019

E-M and the Organ Systems (Part 1)

Dec 10th, 2018

HCC Coding Tool

by Find-A-Code™

How to use Find-A-Code's HCC Coding Tool

Nov 1st, 2018

Anatomy of the Ankle and Common Injuries

by Find-A-Code™

Join Brandon Leavitt as we master the anatomy of the foot and ankle and common diseases and injuries which are found with this joint. We will also cover how these terms are described in ICD-10-CM.

Aug 30th, 2018

Success with Out-of-Network Billing in Today's Environment Part 2

by Find-A-Code™

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.

Aug 16th, 2018

by Find-A-Code™

ICD-10-CM Training - Session 36

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Implanted Spinal Neurostimulators: Document Medical Records

In a recent report, the Office of Inspector General found that Medicare improperly paid claims for implanted spinal neurostimulators when providers didn’t provide sufficient documentation supporting medical necessity. For dates of service on or after July 1, 2021, you must ask your Medicare Administrative Contractor to authorize these services before performing the procedure in the hospital outpatient department.

Learn what you need to include in patient medical records:

Prior Authorization and Pre-Claim Review Initiatives webpage
Section XVII Calendar Year 2021 Hospital Outpatient Prospective Payment System final rule
Section 6.3.2.2 Prior Authorization Program for Certain Hospital Outpatient Department Services (PDF) operational guide
2021 Final List of Outpatient Department Services That Require Prior Authorization (PDF)

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