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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 ...

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Medi-Cal Coverage Criteria for Hospital Beds and Accessories
November 7th, 2018 - Raquel Shumway
Medi-Cal coverage of child and adult hospital beds and accessaries. What is covered and what documentation is required.
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 ...
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...
Risky Business The CMS HCC Risk Model
July 27th, 2018 - Terry Ketchersid, MD, MBA
Today's catchy title may invoke memories of that risqué movie from the 80's starring a young Tom Cruise famously dancing in his "tighty whities." But today's post is not about that type of risk. Instead we are going to spend some time with a risk adjustment model that's quietly become...
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 ...
VA Expands Telehealth
June 14th, 2018 - Wyn Staheli, Director of Research
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 ...
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 ...
Q/A: Billing for GI Anesthesia
March 21st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Medicare’s policy requires the use of a different code when a screening colonoscopy becomes a diagnostic procedure requiring you to bill with CPT code 00811 when treating a Medicare Beneficiary.
Anthem Will Not Give Modifier 25 a Pay Cut
March 1st, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Anthems original plan was to take a 50% reduction when providers reported claims using modifier 25, it was then lowered to a 25% reduction and has now been fully rescinded, to the relief of providers.  The policy was to go into effect March 1, 2018, however, due to strong opposition from ...
Adjusting Your Collection Strategies to HDHPs
January 31st, 2018 - Ashley Choate
High Deductible Health Plans (HDHPs) are recent and growing trend in healthcare that is probably here to stay, regardless of the future changes to the national healthcare system or federal regulations.....
VA Patient-Centered Community Care and Veterans Choice Program: Worth it for Providers?
August 23rd, 2017 - Jared Staheli
As the opportunities for providers outside the VA system expand in order to meet demand, you may be interested in offering services to veterans and the VA, if you are not already. With overwhelming bipartisan support, the opportunities are not likely to abate, but are those opportunities worth it for ...
Health Care Fraud - Don’t Do It!
July 31st, 2017 - Chris Woolstenhulme, CPC, CMRS
If you wonder if what you are doing is fraud, DON’T DO IT! The government takes this extremely serious. I don't need to tell you this.  I have often been apprehensive about making a mistake and I wonder, will it be fraud? Will I spend time in jail for accidentally sending in a duplicate ...
Bulk Risk Scores
May 25th, 2017 - Chris Woolstenhulme, CPC, CMRS
Do you need help with cases and calculating groups of Risk Scores? Per customers request, Find-A-Code now offers BULK entry for calculating for Risk Scores.  The HCC Risk tool offers two options for calculating risk scores, we now offer a BULK calculation for cases or the calculation for a single enrollee. To use the BULK calculation for cases Create ...
CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018
February 15th, 2017 - CMS.gov
The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule for 2018, which proposes new reforms that are critical to stabilizing the individual and small group health insurance markets to help protect patients.
Know how you can leverage your practice performance with 6 revenue cycle metrics
December 20th, 2016 - Ango Mark
Are you one of those busy physicians who pay just a cursory glance at monthly collections? Then you should be prepared to lose revenue every single day like this obgyn practice in southeast Georgia. It is essential for medical practices to track financial performance metrics, as every dollar that...
Workers Compensation
December 7th, 2016 - Wyn Staheli
Workers’ Compensation is for work related illness or injuries on the job. The employer pays for insurance which covers medical costs incurred, and replaces lost wages. Fees are based on a specific fee schedule that varies by state. There are three possible scenarios regarding workers’ compensation: the patient is covered by ...
Dental Offices - Billing Medical Insurance for covered procedures
September 12th, 2016 - Christine Taxin
If your dental office isn’t billing medical insurance for certain procedures, you’re missing out on an important way of serving your patients and expanding your practice. Currently, only about 64% of Americans are covered by a dental insurance plan. But the Affordable Care Act requires nearly 100% of Americans to be covered ...
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...
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...
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...
The Benefit of Checking Benefits
September 3rd, 2014 - Donna Weinstock
Many of your physicians perform surgeries and diagnostic procedures on patients. It is easy to call and determine if precertification is required, but how many of you actually look at what is required of a patient prior to performing the procedure? In many cases outpatient procedures and...
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...
OIG adds to increased scrutiny of how patients pay for rising share of drug costs
May 27th, 2014 - Scott Kraft
Charity programs that help patients pay for the rising cost-sharing obligations of needed drugs may run afoul of anti-kickback rules when the charity’s scope is so narrow that it guides the patient toward specific drugs for treatment or providers, the HHS Office of Inspector General said last...
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...
Health Insurance Exchange implementation: A primer
October 1st, 2013 - Scott Kraft
Health insurance policies issued as part of the state and federal health insurance exchanges under the Affordable Care Act (ACA) will take effect Jan. 1, 2014. That means that, starting on that date, patients may present to your office for insurance coverage under the plans. Here are the things you...
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...

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