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Reimbursement - Articles

Q/A: I Submitted a Claim to the VA and it’s Being Denied. Why?
April 1st, 2019 - Wyn Staheli, Director of Research
I submitted a claim to the VA and it’s being denied. Why? There are several reasons why your claim might be denied by the Veterans Administration (VA). However, without more information about the claim itself (e.g., services billed), we can only provide the following general information about the VA and chiropractic ...
Understanding NCCI Edits
February 20th, 2019 - Aimee Wilcox, CPMA, CCS-P, CMHP, 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 ...
Proposed Rule: Expanded Telemedicine Benefits for Medicare Advantage Beneficiaries
February 14th, 2019 - Aimee Wilcox
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 ...

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Present on Admission POA Indicator
November 26th, 2018 - BC Advantage
This article will focus on the Present on Admission (POA) indicator which is used as a method of reporting whether a patient’s diagnoses are present at the time they are admitted to a facility. We’ll look at a few scenarios to determine the correct reporting of POA and the impact...
Are you Ready for CMS' 2019 Medicare Physician Fee Schedule Final Rule?
November 7th, 2018 - Wyn Staheli, Director of Research
The waiting is over, the Final Rule for CMS' 2019 Medicare Physician Fee Schedule (MPFS) is available - all 2,379 pages for those looking for a little light reading. As anticipated, there are some pretty significant changes. Most of us were carefully watching the proposed changes to the Evaluation and ...
Q/A: What Diagnosis Codes Should I Use for TMJ Headache Massage for Coverage?
October 16th, 2018 - Wyn Staheli, Director of Research
Question: We have been receiving several DDS referrals to our massage therapists who do intra-oral work. The only problem is that the referral from the DDS lists code R51 for headaches as the only DX code. Since most plans don't cover massage therapy for headaches alone, are there any codes that can distinguish the headaches as ...
Q/A: What Codes do I use for CLIA-Waived Tests?
October 16th, 2018 - Wyn Staheli, Director of Research
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 ...
Pelvic Floor Dysfunction Treatment Coverage
October 16th, 2018 - Wyn Staheli, Director of Research
Pelvic floor dysfunction is often the underlying cause of conditions such as pelvic pain; urinary or bowel dysfunction; and/or sexual symptoms. Treatment generally begins with an evaluation and testing (e.g, EMG) followed by a variety of services (e.g., biofeedback, manipulation, pelvic floor electrical stimulation), depending on the findings. Coverage by payers ...
HCC - Acceptable Provider Interpretation for Diagnostic Testing
October 1st, 2018 - Wyn Staheli, Director of Research
The following table is taken from the Contract-Level Risk Adjustment Data Validation Medical Record Reviewer Guidance dated 2017-09-27 (see References). It is a listing of acceptable provider interpretation of diagnostic testing. Acceptable Examples include: Cardiology and Vascular Surgeons Echocardiogram (including Doppler, Duplex, Color flow of the heart vessels) EKG (electrocardiogram) – Stress test, Cardiac ...
The Potential Impacts of a Flat Rate EM Reimbursement on our Industry
September 26th, 2018 - BC Advantage
The proposed E&M changes by CMS would decrease provider administrative work burden by, per CMS, 51 hours a year; however, how will reducing documentation requirements truly affect the professionals of the healthcare industry? First, let’s discuss the 30,000-foot overview of the most impactful E&M changes—which is the change to the...
Getting the Right Eligibility Information for Payment Your Rights and Health Plans Requirement
September 11th, 2018 - BC Advantage
We need timely and accurate patient information to bill health plans and receive appropriate payment. Clinical information is, of course, important. But we also need the "administrative" data - patient demographics and especially the insurance information. Physician offices create their clinical information, but usually rely on patients for information on...
Pricing for ASC’s and APC’s
August 27th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that...
Are incident to services worth the risk
August 13th, 2018 - BC Advantage
Incident-to services allow non-physician practitioners (NPPs) such as nurse practitioners and physician assistants to bill under a supervising physician if they perform services that are incidental to a physician-created plan of care. Incident-to billing offers two key benefits: First, the physician is reimbursed at 100% of the contracted rate with...
Provider-Based Facilities and Split Billing: Is Your Facility Being Reimbursed for All Work Performed?
July 18th, 2018 - NAMAS
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed. For ...
Dual Medicare-Medicaid Billing Problems
July 12th, 2018 - Wyn Staheli, Director of Research
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 ...
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 ...
Provider-Based Facilities and Split Billing Is Your Facility Being Reimbursed for All Work Performed?
June 8th, 2018 - Sharon Hoglund, CPC, CPMA, CEMC, CEMA
Are you stumped by billing guidelines for provider-based facilities? Who bills for what and why? Read on to hear how a little extra time and effort spent on researching split billing coding guidelines can greatly impact your facility, and even your budget ensuring reimbursement for all services performed...
Three Ways Bundled Payments Can Be a Success
June 7th, 2018 - BC Advantage
Bundled payment models continue to attract interest for their potential benefits over traditional fee-for-service payment models. With bundled payments, also known as episode-based payments or packaged pricing, a group of providers is reimbursed based on a contracted price to cover all of the care and services related to a particular ...
UCR Pricing, What is it?
January 25th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
UCR (Usual, Customary, and Reasonable) pricing is a method of generating healthcare pricing based on the average pricing in a particular geographic location.  Gathering information on pricing based on what other providers in that area is charging is commonly used for a fee or payment reference, as it gives a basis ...
Reimbursement for Therapy Students
January 4th, 2018 - Find-A-Code
According to CGS Administrators, qualified professionals may serve as clinical instructors for therapy students within their scope of practice. Physical therapist assistants and occupational therapy assistants may only serve as clinical instructors for physical therapist assistant students and occupational therapy assistant students, respectively, when performed under the direction and supervision ...
Four Final Rules Affecting CMS Payments for 2018
November 7th, 2017 - Wyn Staheli
It’s a season for changes. CMS just finalized four rules which directly impact the following payment systems: Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018 Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes for 2018 HHAs: Payment Changes for 2018 Quality Payment Program Rule for Year 2 This ...
New Payment Rulings Could Affect You
November 6th, 2017 - Wyn Staheli, Director of Research
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems: Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018 Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
Payment Rulings and Small Provider Practices
November 6th, 2017 - Wyn Staheli, Director of Research
Fall has always been the season for CMS fee changes and on November 2, 2017, CMS announced the finalization of four rules which directly impact the following payment systems: Physician Fee Schedule Final Policy, Payment, and Quality Provisions for CY 2018 Hospital OPPS and ASC Payment System and Quality Reporting Programs Changes ...
Big Data & Facility Audit Complex Reviews
September 29th, 2017 - Shannon Cameron, MBA, MHIIM, CPC
Big data and its use in the healthcare spectrum has proven to be an incredible source of the knowledge and has rapidly abetted progress in seemingly all areas of healthcare......
Funding Extended for Veterans Choice Program
August 23rd, 2017 - Jared Staheli
The Veterans Choice Program, created in 2014, was part of the solution to the extensive waiting times found in the VA system. The program allowed veterans to meet their health care needs from private health care providers. Though the “sunset” of the program was avoided earlier in the year, the ...
Do Other States Lower Payments for Crowns by Delta or Blue Cross?
August 11th, 2017 - Christine Taxin
Question: A subscribers from the State of Michigan has asked this: Has anyone from other states seen the fees for crowns lowered by Delta or Blue Cross? Answer: First look at your contracts, and see if there is anything in it that allows for fees to be lowered. Next, look up your ...
How to Bill a Dressing Change
August 1st, 2017 - Chris Woolstenhulme, CPC, CMRS
A dressing change may not be billed as either a debridement or other wound care service under any circumstance (e.g., CPT 97597, 97598, 97602). Medicare does not separately reimburse for dressing changes or patient/caregiver training in the care of the wound. These services are reimbursed as part of a billable procedure code that, commonly but not necessarily, ...
Respiratory Assist Devices (RAD) E0470 and E0471 - Billing Reminders
March 28th, 2017 - Chris Woolstenhulme, CPC, CMRS
Add the KX modifier to all claims for RADs and accessories for the first through third months if all thecoverage criteria have been met. Add the KX modifier to all claims for the fourth month and thereafter if all the coverage criteria have been met and if the physician signed and dated a ...
Alternative Payment Models (APMs) and Advanced APMs
January 16th, 2017 - Wyn Staheli
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 ...
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 ...
Health Risk Assessment
December 13th, 2016 - Chris Woolstenhulme, 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 ...
Discounts
December 7th, 2016 - Wyn Staheli, Director of Research
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 ...
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...
Bundled payment models for coordinated cardiac and hip fracture care
September 15th, 2016 - Chris Woolstenhulme, CPC, CMRS
HHS is proposing new bundled payment models to improve the quality of care and reduce costs for beneficiaries who have a heart attack or undergo bypass surgery. HHS is also proposing to extend its innovative hip and knee bundled payment model to include other surgical treatments for hip and femur ...
3 Steps To Be As Successful As University Of Virginia’s Medical Group Practice.
July 19th, 2016 - Adam Smith
How keeping track of the key performance indicators has given this group practice an edge over its competitors in handling the revenue cycle… The shift to value-based economic systems has de-stabilized many healthcare organization’s economic dispositions. Group practices endured...
How group practices are surviving the value based payment model in 2016!
June 3rd, 2016 - Adam Smith
As the healthcare industry undergoes dramatic transformation, group practices are facing a lot of turbulence to their financial structuring. Moving away from fee-for-service business models to value-based reimbursement setup is a daunting endeavor, but, that’s where the industry is heading...
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...
The Critical Role Of Hospital CFOs: A Data Driven Answer [Infographic]
October 6th, 2015 - Adam Smith
We know the evolving role of CFOs in the healthcare industry. There are situations which have forced the executives to make such decisions like changing the vendor, attritions and outsourcing one or more of their processes. There could be ample reasons like transition to value-based model, slow...
Money In Your Pocket: Balance Bill
December 4th, 2014 - Donna Weinstock
Do you routinely balance bill your patients? Do you send the statement as soon as you hear from insurance or do you wait until the end of the month? Balance billing your patients is essential for several reasons. First, it increases your revenue. It may not seem like a lot of money, but the...
MACs may change the way electronic payments are issued, processed
December 4th, 2014 - Scott Kraft
Medicare already required its Medicare Administrative Contractors to pay you via electronic funds transfer (EFT) in most instances. But a recent policy change that requires all private insurance plans to offer EFT may result in tweaks to how the MACs pay as well. In transmittal 135 to its...
Don’t expect beneficiaries to pick up the slack for PQRS, EHR cuts
December 4th, 2014 - Scott Kraft
2015 is a big year for payment adjustments for providers who’ve failed to take part in CMS incentive programs for electronic health records (EHR) meaningful use, e-prescribing and the Physician Quality Reporting System (PQRS). It’s the year that CMS goes from dangling the carrot...
Win The Losing Battle-Verify
August 5th, 2014 - Donna Weinstock
Do you feel like you are fighting a losing battle? Are you watching your account receivables going up and your collections going down? Is your cash flow suffering? What is a practice to do? One of the most effective ways to keep your cash flowing is by checking your patient’s...
Dreams of permanent pay fix fade as House passes one-year SGR fix; ICD-10 also faces potential delay
March 27th, 2014 - Scott Kraft
Leaders on Capitol Hill spent so much time debating, discussing and even reaching a tentative deal on a permanent repeal to the Sustainable Growth Rate (SGR) formula that has caused so much payment uncertainty for physician practices that people started to think it would actually happen. It looks...
Interim pay raise set to take effect Jan. 1 while legislators attempt permanent Medicare fee fix
January 30th, 2014 - Scott Kraft
Your practice is starting 2014 with yet another patch to the sustainable growth rate formula that has hampered Medicare payments to doctors for years. There is reason for cautious optimism this time, however, as the three-month pay fix is designed to give extra time to pass a permanent fix to the...
2014 Billing and Coding Primer for Therapy Services
December 10th, 2013 - Scott Kraft
The release of the 2014 Physician Fee Schedule Final Rule in late November, coupled with the scheduled expiration of certain provisions of the American Taxpayer Relief Act (ATRA) threatens to add a lot of confusion to how you bill for therapy services in 2014. We’re here to help. First, the...
Who Qualifies for TCM Services?
April 22nd, 2013 - Lacy Gaskins
Any patient post-discharge whose medical and/or psychosocial problems are complex enough to require TCM services qualifies for these codes. Here are the specifics:   1. Location: “TCM is for higher-risk patients being discharged from an inpatient or observation status to their home, rest home,...
Using Modifer -59
March 31st, 2009 - Crystal Reeves
By Crystal Reeves, CPC, CMPE, Principal Modifier -59 is probably one of the most misunderstood, misused, and most-feared of all CPT® modifiers. Some practices avoid using it all together because they don’t want to be guilty of unbundling. Some practices do not use it because they are not...
Services denied as incidental to another service
March 3rd, 2009 - Codapedia Editor
Have you received a denial from a payer with these words? "This service was denied as incidental to another service." Notice that the payer does not say that the service was bundled into another service. The explanation of benefits from the commercial payer uses the word...
Prolonged Services: A General Discussion
February 18th, 2009 - Codapedia Editor
Prolonged services are add on codes, used to indicate that the physician or Non-Physician Practitioner spent 30 minutes more than the typical time for that code with the patient. See the Codapedia articles on prolonged services in the office (face-to-face) and prolonged services in the hospital...

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