Claims - Articles

A United Approach
June 14th, 2019 - 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 ...
What Medical Necessity Tools Does Find-A-Code Offer?
June 13th, 2019 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT, Director of Content
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 ...
Q/A: How Many Diagnosis Codes do I use?
April 15th, 2019 - Wyn Staheli, Director of Research
Question: My patient has a lot of chronic conditions. Do I need to include all these on the claim? I know that I can have up to 12 diagnoses codes on a single claim. What if I need more than that? Answer: More is not always better. You only need to ...
Prolonged Services
March 29th, 2019 - Namas
Prolonged Services I find in my own audit reviews that the prolonged service code set is often mistreated: they are avoided and not used even when the scenario supports them, or they get overused and improperly documented. Prolonged services are used in conjunction with all types of Evaluation and Management (E/M) ...
Date of Service Reporting for Radiology Services
March 7th, 2019 - Wyn Staheli, Director of Research
Providers need to ensure that they are reporting radiology dates of service the way the payer has requested. Unlike other many other professional services which only have one date of service (DOS), radiology services can span multiple dates. Medicare requirements may differ from professional organization recommendations.

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Q/A: Do Croft Guidelines Apply After Time has Passed Since the Accident?
November 28th, 2018 - Tom Grant Jr. DC
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?
Join QPro Today and Get Certified
September 12th, 2018 - 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 ...
Keys to Successful Claims Filing
August 30th, 2018 - Noridian Medicare
There are many factors that can contribute to your success in filing claims and getting reimbursed. The information below is from the CMS website. Completing Item 12, Patient's or Authorized Person's Signature, on the CMS-1500 form for a non-assigned claim A signature on file (SOF) indicates the supplier has obtained the beneficiary's one-time authorization on ...
WHO Said ICD-11 is Coming Soon
June 26th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Sooner or later ICD-11 will be released, and it sounds like it will be sooner than later. WHO released the news on June 18, 2018. The World Health Organization stated “ICD-11 will be presented at the World Health Assembly in May 2019 for adoption by Member States, and will come ...
Why Is Medicare Denying My Claims for Mammography and Breast Biopsies?
June 4th, 2018 - BC Advantage
When Medicare updated their systems with the updates to mammography and breast biopsy policies some ICD-10-CM codes were inadvertently left out. The omitted new codes are N63.11-N63.14, N63.21-N63.24, N63.31, N63.32, N63.41, and N63.42, which will replace the truncated ICD-10 diagnosis N63. The Centers for Medicare & Medicaid Services (CMS) will...
Q/A: I am Having Trouble with a Claim Rejection on my PI Claim. What do I do?
April 12th, 2018 - Wyn Staheli, Director of Research
Question: I have a patient that was involved in a PI case. His lawyers are asking that we bill his insurance company first. This particular patient has xxxx insurance and the clearing house is rejecting the claim based on "ERROR 3430-Invalid principal diagnosis code." We lead with diagnosis code V43.52XA, could we change the position of the V43.52XA code? Or should we submit a paper claim for the case instead?
Avoiding D9 Denials
March 26th, 2018 - Nicole, QCC
The following is according to WPS. Please make sure what is bold below is entered verbatim on the second line of the "Remarks" section. This should be the only thing on the second line of remarks: Patient control nbr - If you are changing or adding a patient control number Admission hour - If you are changing or adding the admission ...
OIG Reviews Medicare Advantage Claims
February 1st, 2018 - Wyn Staheli, Director of Research
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; ...
Insufficient Documentation Errors
January 29th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
According to CMS ICN 909160, claims are determined to have insufficient documentation errors when the medical documentation  submitted is inadequate to support payment for the services billed, meaning the reviewer could not conclude that some of the allowed services were actually provided, were provided at the level billed, and/or were medically necessary. Claims ...
Referring and Ordering Physician - CMS-1500 Box 17
January 29th, 2018 - Christine Woolstenhulme, QCC, CMCS, CPC, CMRS
Enter the name of the referring or ordering physician if the service or item was ordered or referred by a physician. All physicians who order services or refer Medicare beneficiaries must report this data. Similarly, if Medicare policy requires you to report a supervising physician, enter this information in Item ...
Revenue Cycle 101: Reduce your Denials with These Tips
January 24th, 2018 - Ranadene Tapio, MBA, CMRS, CMC
Your practice seems to be doing everything right. You have a team in place, established your RCM process and you’re submitting claim after claim – but your denial rate isn’t going down....
$4.6 million in Claims Paid Incorrectly by CMS when Using KX Modifier
January 16th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
$4.6 Million was paid by CMS for claims that did not comply with Medicare requirements.  The claims were paid in 2017 and reported by the Office of Inspector General (OIG) stating, "A 2017 Office of the Inspector General (OIG) report noted that, in some cases, pharmacies incorrectly billed Medicare Part B ...
Patient Relationship Codes
January 16th, 2018 - Wyn Staheli, Director of Research
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 ...
Filing a CMS-1500 Claim form to Medicare PUB-100 40.1.1.1
January 4th, 2018 - Find-A-Code
An independent clinical laboratory may file a paper claim form shall file Form CMS-1500 for a referred laboratory service (as it would any laboratory service). The line item services must be submitted with a modifier 90. An independent clinical laboratory that submits claims in paper format) may not combine non-referred (i.e., ...
Escharotomy Procedural Cross-Walking CPT to ICD-10-PCS
November 10th, 2017 - Brandon Dee Leavitt CPC, QCC
An Escharotomy is used for "local treatment of burned surface" per the AMA Guidelines, when incisions are performed on the burn site. Notice, when cross-walking 16035 or 16036 to inpatient codes, Find-A-Code crosswalks lead to Body System H, Operation 8 - Division of the skin, and Operation N -...
Medicare Improper Payment Report for Behavioral Health Services (2016)
September 1st, 2017 - Wyn Staheli
The Medicare Improper Payment Report for 2016 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from ...
Medicare Improper Payment Report for Chiropractic (2016)
September 1st, 2017 - Wyn Staheli
The Medicare Improper Payment Report for 2016 has been released by the OIG. Please note that the improper payment rate does not measure fraud. Rather, it estimates the payments that did not meet Medicare coverage, coding, and billing rules. The estimated Medicare FFS payment accuracy rate (claims paid correctly) from ...
Covered colonoscopy is attempted but cannot be completed due to extenuating circumstances
December 21st, 2016 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Medicare will pay for the interrupted colonoscopy as long as the coverage conditions are met for the incomplete procedure. However, the frequency standards associated with screening colonoscopies will not be applied by CWF. When a covered colonoscopy is next attempted and completed, Medicare will pay for that colonoscopy according to ...
VACCINE AND VACCINE ADMINISTRATION PAYMENTS UNDER MEDICARE PART D
December 16th, 2016 - Brittney Murdock, QCC, CMCS, CPC
Please note: The information in this publication applies only to Medicare Part D; the Prescription Drug Benefit. Except for vaccines covered under Medicare Part B, Medicare Part D plans cover all commercially available vaccines as long as the vaccine is reasonable and necessary to prevent illness. Health care professionals (sometimes known as ...
Are harder times coming for CFOs? A data driven answer [Infographic]
October 13th, 2016 - Ango Mark
“We really do believe much harder times are coming from a reimbursement standpoint”, Daniel Morissette, Stanford Health Care CFO. With value based model, the most unpredictable payment reform, in their list of financial challenges, CFOs point out their threats and decision making...
23 RCM questions you should ask when reviewing a medical billing company
September 29th, 2016 - Ango Mark
So, you have considered taking on the challenges of finding the best medical billing company for your medical practice. We should all by now know that the healthcare industry’s reimbursement laws aren’t going to stay put and be as they are. The changes they undergo are constant and...
6 Simple steps to create secondary claims using eClinicalWorks!
March 16th, 2016 - Victoria
With the help of web analytics , question and answer websites, forums, we came across the most searched queries . And, today we will discuss one of them. We reached out to Sophia Johnson,eClinicalWorks billing specialist at PracticeBridge to share her insights and she provided us six simple steps to...
How to submit Medicaid/Medicare secondary claims electronically using eClinicalWorks!
March 15th, 2016 - Victoria
It has never been a cakewalk working with an EHR. You know how tough it can be, if you don’t have an eClinicalWorks expert to help you with billing needs. What do you do when you are not aware of a certain feature or a procedure? We reached out to some organizations to know how what they did...
Are you ready for the value based payment model?
March 15th, 2016 - Victoria
Healthcare professionals are being forced to move out of their comfort zones. Sweeping changes are being made to change the way healthcare is provided and paid for. 40% of in-network payments are tied to value. And the traditional fee for service model is expected to disappear over the horizon in...
What Does It Mean To Scrub An Insurance Claim?
December 29th, 2015 - David Greene, MD
During the rigorous training physicians undergo to learn their craft, very little education is received on how to deal with submitting claims to insurance companies. It’s unfortunately a necessary evil, as surgeons who contract with insurance companies rely on that reimbursement as the...
Not Documented, Not Done: Medicare Myth or Rule?
December 29th, 2015 - Codapedia Staff
After years of unchallenged recitation, the coding community has virtually canonized the phrase “not documented—not done” into coding scripture. But there are good reasons to question whether the now-famous epigram reflects an actual rule or whether it has simply taken on a life of...
Make sure your smoking cessation services are being coded right
June 1st, 2015 - Scott Kraft
Coding, billing and getting paid for providing smoking cessation services when covered by your payers is almost a no-brainer for any physician practice because, in most cases, cessation services are already being provided to patients who smoke cigarettes. Yet practices consistently...
‘Two midnight’ rule draws lawsuit – enforcement currently delayed
August 5th, 2014 - Scott Kraft
The American Hospital Association is leading the charge in a lawsuit against CMS’s controversial “two-midnight rule,” instituted last year to attempt to slow down the expanded use of observation status by hospitals by presuming that any stay intended to cover two or more midnights...
Claims to be held by CMS for first 10 business days of April
March 28th, 2014 - Scott Kraft
While Congress hashes out whether and how to avert the more than 20 percent pay cut now set to start on April 1, CMS is making its own contingency plans to avoid paying out a lot of claims that will need to be re-processed later, if Congress ends up missing the April 1 deadline for action. CMS...
CMS-1500 form revised to fit more diagnosis codes, less patient demographic information
February 28th, 2014 - Scott Kraft
CMS-1500 form revised to fit more diagnosis codes, less patient demographic information It doesn’t get used nearly as much as it used to, but there is a new CMS-1500 claim form that has been revised slightly to fit more diagnosis codes and to facilitate the transition to the ICD-10-CM coding...
As of Jan. 1, your practice can insist of electronic funds transfer payments from payers
February 16th, 2014 - Scott Kraft
One provision of the Affordable Care Act (ACA) that can work to your practice’s advantage is Section 1104, which gives you the right to insist on electronic funds transfer (EFT) as your method of payment. As of Jan. 1, 2014, you are entitled to EFT payments upon your request under standards...
6 ways to stop filing duplicate Medicare claims
December 4th, 2013 - Scott Kraft
Whenever a Medicare Administrative Contractor (MAC) releases a list of the top reasons for claims denials, the list almost never fails to include duplicate claims. When the MAC perceives the claim to be a duplicate, based typically on a match of the patient identifying information, furnishing...
Medicare Part B deductible, premiums to be unchanged for 2014; tips on deductible collection
October 31st, 2013 - Scott Kraft
The Medicare deductible for Part B services will not change in 2014, remaining at $147 for the second straight year. The premium for beneficiaries will also remain unchanged at a base rate of $104.90, continuing the slowest five-year period of premium growth in Medicare Part B history, according to...
Hospital Observation Services
August 28th, 2013 - Dorothy Steed
Hospital observation services are considered outpatient services. They are typically used when a period of time is needed to evaluate the progress or regression. This may include effectiveness of medication/ infusions, results of diagnostic results or other reasons deemed as medically necessary....
Charging Medicare Patients for Missed Appointments
June 20th, 2013 - Cyndee Weston
Previously, each Part B office had their own requirements regarding charging Medicare patients for missed appointments. TRICARE (TriWest Healthcare Alliance) regulations required providers to establish office practice policies regarding "no show" fees and required beneficiaries to sign an...
EMRs - Coding and Compliance Concerns
April 24th, 2013 - Allison Singer, CPC
Introduction The past year has been an exciting time for healthcare professionals, bringing more changes, opportunities and challenges than ever before. The Health Information Technology for Economic and Clinical Health (HITECH) Act, which is a portion of the American Recovery and Reinvestment Act...
Keeping Track of Your Surgeries
March 22nd, 2013 - Debra Sanders
When working my AR, I work my surgeries separately since that is my big money or bulk money. I want to make sure I get that money in as quickly as possible. For me, I created an excel spreadsheet. The columns are: DOS - PATIENT NAME/MRN - PROC NAME - CARRIER(S) - CPT® - MODIFIER - BILLED -...
No Claim Left Behind
March 22nd, 2013 - Shannon Bosley
Call me crazy, but it is always exciting to me when I assist a practice in getting reimbursed on unpaid or delinquent claims. Claims that were denied, viewed as uncollectable, past filing deadline, or a multitude of other reasons. I even have a little dance that I do! Why not? We need to get...
Why Get Into Medical Billing?
March 22nd, 2013 - Debra Sanders
I am asked alot or read alot where people want to get into medical billing. Some have gone to school and some haven't. Either way, there is more to it than just saying, I want to do that. I've been in this field for over 15 yrs and still learn something new every day. I even learn something I...
Preventive Medicine Services for Medicare Patients
April 10th, 2009 - Codapedia Editor
The most widely known fact about Medicare and preventive medicine is that fee-for-service Medicare does not cover an annual physical exam. This is because in its beginning, Medicare was prohibited from paying for routine services. Over the years, Congress has mandated the payment of some screening...
Real Time Claims Adjudication (RTCA)
March 31st, 2009 - Codapedia Editor
Real time claims adjudication (RTCA) is a software interface between a physician's practice management information system and a payers claims processing system that allows the practice to submit a claim at the time of checkout, and receive a response from the insurance company while the patient is...

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