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Medicare - Articles

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.
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 ...
Common Allergy CPT Codes and MUEs
October 30th, 2018 - Find-A-Code™
Below is a list of common CPT codes for Allergy and Immunology. Each code is listed with the following information: Medicare Unlikely Edits (MUEs) for both a Non-Facility (NF) and Facility (F) setting. Professional/Technical Component (PC/TC) Indicator. Key Indicator or Procedure Code Status Indicator, which is a Medicare assigned "Indicator" to each code in ...
Allergy Testing 10/29/2018
October 29th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Allergy testing may be performed due to exaggerated sensitivity or hypersensitivity.  Using findings based on the patient’s complaint and face-to-face exam. Testing may be required to identify and determine a patient's immunologic sensitivity or reaction to certain allergens using certain CPT codes.  According to CMS, LCD 33261, allergy testing can be ...
Chiropractic OIG Audit Recommendations - Lessons Learned
September 28th, 2018 - Wyn Staheli, Director of Research
The OIG recently concluded an audit on a chiropractic office located in Florida and had some significant findings. They recommended the following: Refund to the Federal Government the portion of the estimated $169,737 overpayment for claims for chiropractic services that did not comply with Medicare requirements and are within the 4-year ...
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...
PSAVE Pilot Program - What Does it Mean to You?
August 20th, 2018 - Wyn Staheli, Director of Research
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?
Medicare Timed Codes Guidelines
August 16th, 2018 - Wyn Staheli, Director of Research
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 ...
Patients Over Paperwork?! We have Great News!
July 18th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Spend more time with patients and less time documenting? Great Concept! Document meaningful information? Sound good? CMS is proposing just that! CMS released a new proposal July 12, 2018, focused on streamlining clinician billing and expanding access to high-quality care. The goal is to improve and restore the doctor-patient relationship, modernize Medicare ...
Attention Providers - Please Make Time to Read this Letter
July 17th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
In an effort to show CMS is committed to changing the rules to accommodate their providers CMS released a letter to Doctors of Medicare Beneficiaries. The letter offers encouragement and a promise to reduce the burden of unnecessary rules and requirements. The letter states “President Trump has made it clear that ...
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 ...
Will Medicare's Proposed Reformations Affect Your Practice?
June 12th, 2018 - Wyn Staheli, Director of Research
Recently, Medicare's Innovation Center released an informal Request for Information (RFI) seeking input on several different system reformation proposals. As the market moves towards more value based payment systems, innovation and new models are being sought to both reduce costs and increase quality. This article outlines the ideas presented in the ...
AMA vs Medicare rules and the use of the PT modifier
May 22nd, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
Be sure to review the specific payer policy you are submitting claims to. 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. The use of the PT modifier is ...
Documentation for Enteral Nutrition
March 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for enteral nutrition. ...
Documentation for Ordering Oxygen Supplies and Equipment
March 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for Ordering Oxygen Supplies and Equipment.
Documentation for Urological Supplies
March 9th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for urological supplies.
Delivering Bacterial Culture Lab Orders
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on delivering orders for bacterial culture laboratory tests...
Preventing Denials for Home Blood Glucose Monitors (BGM)
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on how to Prevent Denials for Home Blood Glucose Monitors (BGM)...
Documentation and Orders for Laboratory Tests
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for ordering laboratory tests.
Documentation and Orders for Respiratory Assistive Device
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for a respiratory assistive device and ordering guidelines.
Documentation for Skilled Nursing Facilities
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for Skilled Nursing Facilities (SNF).
Documentation for Inpatient Rehabilitation Facilities
March 8th, 2018 - Medicare Learning Network
The Medicare Learning Network provides guidance on required documentation for Inpatient Rehabilitation Facilities (IRF).
Documentation for Home Health Services (Part A non DRG)
March 8th, 2018 - Medicare Learning Network
The Medical Learning Network provides coverage guidance, which should be documented, for home health services.
No HCPCS Code Available? Now What?
February 21st, 2018 - Chris Woolstenhulme, 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 ...
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 ...
Creating a Culture of Compliance in 2018
January 26th, 2018 - Sean M. Weiss, CHC, CEMA, CMCO, CP MA, CPC-P, CMPE, CPC
This year (2018), health care organizations (Hospitals, Health Systems and Physician Groups/Practices) must focus on the criticality of creating a culture of compliance to ensure effectiveness and efficiency....
Psychiatric Partial Hospitalization Programs
January 25th, 2018 - Wyn Staheli, Director of Research
Psychiatric Partial Hospitalization Programs (PHPs) are a more comprehensive level of care than Intensive Outpatient Programs (IOPs - click here to read more about IOPs). When the patient requires a minimum of 20 hours per week and hospitalization is not clinically indicated, a PHP can be the most effective type of ...
NEW on Find-A-Code...National Coverage Determinations (NCDs)
January 23rd, 2018 - Aimee Wilcox, CPMA, CCS-P, CMHP, CST, MA, MT
Medicare limits its coverage of services to those considered to be reasonable and necessary for the diagnosis and treatment of an injury or illness based on coverage guidelines. National Coverage Determinations (NCDs) are created based on research, evidence-based processes, public participation, and other resources, and made available to the public. ...
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 ...
Medicare Requiring Specific Modifiers on Therapy Services
January 15th, 2018 - Wyn Staheli, Director of Research
Medicare's MLN Matters Number: MM10176 was recently revised to identify services subject to their therapy cap. The revision became effective on January 1, 2018 and some providers have begun to receive claim rejections because they are not using the appropriate modifier. The article states the following: Services furnished under the Outpatient ...
Intensive Outpatient Treatment (IOP)
January 11th, 2018 - Wyn Staheli, Director of Research
Intensive Outpatient Programs (IOPs) are considered to be an intermediate level of care which is commonly considered after the patient has been discharged from inpatient care. For some patients and/or conditions they can also provide an effective level of care when hospitalization is not clinically indicated or preferred. The following ...
MIPS - To Participate or Not Participate - That is the Question
January 10th, 2018 - Wyn Staheli, Director of Research
Medicare’s Merit-based Incentive Payment System (MIPS) Final Rule increased the threshold for participation. With this increase, a significant number of providers fall into the exempt category and they are now breathing a sigh of relief. However, there’s one hidden tidbit which you may have missed - the potential damage to ...
Medicare Reimburses for Discarded/Wasted Drugs
January 5th, 2018 - Aimee Wilcox, CPMA, CCS-P, CST, MA, MT
Your organization may be leaking revenue without realizing the leak can be stopped. If your organization purchases single-use packets or single dose vials for individual patient use and ends up discarding some of the drug, Medicare has now authorized payment for the discarded or wasted portion. Stop leaking revenue today by reading this article and implementing the guidance provided here.

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Medicare Diabetes Prevention Program (MDPP) Expanded Model Information
December 12th, 2017 - Jared Staheli
Diabetes treatment places an ever-increasing strain on the resources of the U.S. healthcare system. CMS estimated that in 2016 alone, Medicare incurred an additional $42 billion in costs due to the number of beneficiaries with diabetes. The best way to keep these costs down in the future is by preventing ...
Understanding ASC Pricing
November 22nd, 2017 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
ASCs (Ambulatory Surgical Centers) have a separate fee schedule with a base allowed amount that is adjusted for each state using Core Based Statistical Areas (CBSA). Under the ASC payment system, Medicare pays facilities for specific ASC covered surgical procedures, however, there are only certain types of procedures that are eligible for payment ...
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 ...
E&M Guidelines with NGS is Not Mandatory
September 20th, 2017 - Chris Woolstenhulme, CPC, CMRS
Changes with the 1995 Documentation Guidelines for Evaluation and Management services, is not considered mandatory. NGS had originally planned a change in examination requirements for Expanded Problem Focused and Detailed levels of service. The decision to not mandate the changes was due to feedback and multiple provider queries from NGS providers. All medical records that are reviewed will be ...
Medicare Improper Payment Report (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...
Preventive Services: Alcohol Misuse Screening and Counseling
September 1st, 2017 - Find-A-Code
The following information from the Medicare Learning Network (MLN) provides guidance on Alcohol Misuse Screening and Counseling.......
Preventive Services: Annual Wellness Visit (AWV)
September 1st, 2017 - Find-A-Code
The following information from the Medicare Learning Network provides guidance on Annual Wellness Visits (AWV)
Changes to the Medicare Appeals Process
August 25th, 2017 - Sean Weiss, CHC, CMCO, CEMC, CPMA, CMPE, CPC-P, CPC
On June 29th, The Centers for Medicare and Medicaid (CMS) issued the Medicare Program: "Changes to the Medicare Claims and Entitlement, Medicare Advantage and Organization Determination, and Medicare Prescription Drug Coverage Determination Appeals Procedures final rule."
Medicare Announces New Cards to Be Issued
August 17th, 2017 - ChiroCode
Identity theft has become a major problem in the United States. As a prevention measure, the Centers for Medicare& Medicaid Services (CMS) is readying a fraud prevention initiative that removes Social Security numbers from Medicare cards to help combat identity theft, and safeguard taxpayer dollars. Personal identity theft affects a large ...
NEW Mandatory ABN Form to Take Effect June 21, 2017
August 17th, 2017 - Mario Fucinari DC, CCSP, CPCO, MCS-P, MCS-I
The Centers for Medicare and Medicaid Services (CMS) has revised the Advanced Beneficiary Notice of Non-coverage (ABN) Form. The revised Advanced Beneficiary Notice of Non-coverage (ABN), Form CMS-R-131, is issued to the patient or client by providers, physicians, practitioners, and suppliers in situations where Medicare payment is expected to be ...
Increased Medicare payment rates for FY 2018!
August 4th, 2017 - Chris Woolstenhulme, CPC, CMRS
We can look forward to a few prospective payments for Skilled Nursing Facilities, Hospice and Inpatient Rehab; CMS released their final rule and reported on key highlights of the new FY 2018 Medicare payment rules. CMS States, “The 2018 Skilled Nursing Facility (SNF) Prospective Payment System Final Rule increases Medicare payment rates ...
Proposed Payment Changes in 2018 and 2019 for Medicare Home Health Agencies
July 26th, 2017 - Chris Woolstenhulme, CPC, CMRS
CMS announced today the payment rates and wage index system for 2018 has a new proposed rule for Medicare Home Health Agencies.  CMS stated, “The new payment system aims to encourage innovation and collaboration and to incentivize home health providers to meet or exceed industry quality standards.”  The proposed rule ...
New payments for Psychiatric Collaborative Care Services (COCM) from Medicare
June 29th, 2017 - Chris Woolstenhulme, CPC, CMRS
Medicare has agreed to make separate payments to physicians and non-physicians for Behavioral Health Integration (BHI) services beginning Jan. 1st, 2017. Any condition new or pre-existing behavioral health or substance use disorders are eligible. Beneficiaries may have comorbid, chronic, or other medical conditions they are being treated for as well. Using the ...
CMS Overpaid Providers $729 Million in Incentive Payments
June 16th, 2017 - Chris Woolstenhulme, CPC, CMRS
Medicare paid hundreds of millions in electronic health record incentive payments that did not comply with federal requirements according to the OIG.  The OIG estimated CMS inappropriately paid $729,424,395 to EPs who did not meet the requirements for meaningful use. Eligible professional’s (EP’s) are physicians, dentists, podiatrists, optometrists or chiropractors, if ...
Auditing Incident-to Services
June 16th, 2017 - Michael Miscoe, Esq.
To effectively audit incident-to services under Medicare, the auditor must first have an operational understanding of the rule. Unfortunately, this is not as easy as it sounds. Auditors must also understand that the incident-to rule is a Medicare only rule. This is one area where the maxim "if you are ...
Billing Medicare for Certain Replaced Devices
June 8th, 2017 - Chris Woolstenhulme, CPC, CMRS
When billing for certain replaced devices, Medicare payments should be reduced when a replacement device (cardiac or otherwise) is received by a hospital at a reduced cost (including no cost), or with a credit that is 50 percent or greater than the cost of the device. Correct billing in such situations ...
Therapy Caps, Limits and Providers
May 4th, 2017 - Chris Woolstenhulme, CPC, CMRS
The annual combined therapy cap is per beneficiary each calendar year. For 2017, this includes Medicare Part B outpatient therapy cap for Occupational Therapy (OT) $1,980, Physical Therapy (PT) and Speech-Language Pathology Services (SLP) $1,980. In addition there is an exception process, if the therapy services are higher than the limited amounts, the beneficiary ...
April 28th, 2017 - Christine Taxin
Prescribers, including dentists, who write prescriptions for Part D drugs are to be enrolled in an approved status or validly opted out with Medicare, in order for their patients’ prescriptions to be covered under Medicare Part D. Full enforcement of Part D prescriber enrollment requirement will begin on January 1, 2019. ...
The Quality Payment Programs
April 24th, 2017 - Chris Woolstenhulme, CPC, CMRS
Medicare has given the option for participation in the Quality Payment Program offering two tracks you can choose from as well as the option to pick your pace. You can choose to start anytime between January 1 and October 2, 2017: Advanced Alternative Payment Models (APMs) or The Merit-based Incentive Payment System ...
Acute Postoperative Pain Management
March 20th, 2017 - Wyn Stahel
Caution needs to be observed when reporting post-operative pain management (POPM). In accordance with NCCI edits policies, postoperative pain management is considered bundled in the surgical code(s). There are only a few instances where it may be billed separately. Medicare Global Surgery Rules prevent separate payment for postoperative pain management when ...
Medicaid Reviews
February 23rd, 2017 - Wyn Staheli
All federal healthcare programs are required to implement programs to prevent and reduce provider fraud, waste, and abuse and this includes the Medicaid program. Two groups work in conjunction with the Centers for Medicare and Medicaid Services (CMS) and the Office of the Inspector General (OIG): the Medicaid Integrity Program (MIP) works at ...
CMS Issues Proposed Rule to Increase Patients’ Health Insurance Choices for 2018
February 15th, 2017 -
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.
Medicare Conversion Factor
February 8th, 2017 - Wyn Staheli
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 ...
Medicare Revises their Appeals Process
February 6th, 2017 - Wyn Staheli
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. ...
Medicare Coverage of Behavioral Health Services
February 1st, 2017 - Wyn Staheli
Medicare's coverage of mental health services is based upon the medical necessity as defined within the Medicare Benefits Policy Manual and the Local Coverage Determinations (LCDs). It should also be noted that not all types of providers may perform all Medicare covered services. For example, an...
Sleep Studies: Billing with Reduced Hours
January 12th, 2017 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS
When using codes 95800, 95801, 95806, 95807, 95810, and 95811, and fewer than six hours of recording is performed, you must report the reduced services using modifier 52. Also, when using 95782 and 95783, and fewer than seven hours of recording is performed, modifier 52 would be appended to the appropriate code. 95805 would require modifier 52 if fewer than four hours of recording is performed. Medicare recognizes the ...
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...
December 20th, 2016 - Evan M. Gwilliam DC MBA BS CPC CCPC QCC CPC-I MCS-P CPMA CMHP
This handy FAQ addresses the uses and mis-uses of the ABN form.
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 ...
CMS Announces Additional Opportunities for Clinicians Under the Quality Payment Program
December 15th, 2016 - Brittney Murdock, CPC
Today, the Centers for Medicare & Medicaid Services (CMS) announced more new opportunities for clinicians to join Advanced Alternative Payment Models (APMs) to improve care and earn additional incentive payments under the Quality Payment Program, which implements the Medicare Access and CHIP Reauthorization Act of 2015 (MACRA). Beginning in January...
60 Day Final Rule
December 12th, 2016 - Wyn Staheli, Director of Research
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.
MACRA facts that every clinician should know [Infographic]
November 11th, 2016 - Adam Smith
MACRA is here and the new program is going to sunset several (un) popular programs such as Meaningful Use and the Value Based Payment Modifier model. Everybody who is anybody is busy discussing about MACRA and its ramifications. But as with any big updates the myths are jostling for space with the...
Government Healthcare Programs
September 17th, 2016 - Wyn Staheli
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 ...
Vaccines are Not Just for Kids
August 16th, 2016 - Find-A-Code
National Immunization Awareness Month (NIAM) is an annual observance held in August to highlight the importance of vaccination. All adults should get vaccines to protect their health. Even healthy adults can become seriously ill, and can pass certain illnesses on to others. Talk to your Medicare patients about vaccines they ...
When the Government Tries to Change the Rules
August 11th, 2016 - Sean Weiss
We all know that the government doesn't fight fair. This is why it is so critical for healthcare professionals to understand their recourse when the government does not follow their own guidelines. Providing audit appeal defense services to clients all over the country, we are seeing MACs and ZPICs making determinations ...
1500 Claim Form Tips
August 3rd, 2016 - ChiroCode
The following rules for the 1500 claim form are excerpts from NUCC and Medicare instructions, but they are generally universal and apply to claims submitted either electronically or on paper. Please note that payment rules can change frequently for any payer, so consult with specific insurance payers for their adaptations. The ...
ICD-10 Changes for 2017
August 3rd, 2016 - Wyn Staheli
The Centers for Medicare & Medicaid Services (CMS) recently released the Proposed Rule regarding the updates to the ICD-10-CM and ICD-10-PCS code sets for Fiscal Year 2017 which begins October 1, 2016. Comments regarding the proposed ICD changes are due May 6th and CMS has stated that the Final Rule ...
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...
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...
E/M service prior to a screening colonoscopy
December 29th, 2015 - Codapedia Editor
CMS does not pay for an Evaluation and Management service prior to a screening colonoscopy. If a patient calls or is sent from another physician to schedule a screening colonoscopy, do not bill any type of E/M service prior to the procedure. Some commercial carriers also follow this policy. If...
Cloned E/M notes
December 29th, 2015 - Codapedia Editor
Have you ever read a physician office note and thought it was strangely familiar? Or, not just familiar but identical to another note? Well, Medicare contractors have noticed the same thing, and the Office of Inspector General has included this on their 2011 Work Plan. Medicare contractors have...
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...
Subsequent Observation Services
October 15th, 2015 - Codapedia Editor
CPT® released three new E/M services in 2011, to be used for the second and subsequent days that a patient is in observation status in the hospital. The codes are 99224--99226 and they are out of sequence in the CPT® book. They require the same level of documentation as the three...
Post-operative Hospital Visits
October 15th, 2015 - Betsy Nicoletti, M.S., CPC
In 1992, CMS developed the concept of the Global Surgical Package, which pays for surgical services with a single payment. The full description of services that are included in this payment is described in the Medicare Claims Processing Manual, Chapter 12, Section 40 and in a CMS Fact Sheet.
Teaching Physician Rules
October 15th, 2015 - Betsy Nicoletti
The teaching physician (TP) rules describe a payment method by which Medicare pays an attending physician or teaching physician for services performed jointly with an intern, resident, or fellow, in an approved graduate medical education program (GME). The teaching physician’s presence and participation is required.
Coding for Screening Colonoscopies
October 15th, 2015 - Codapedia Editor
How to code for screening colonoscopies, what modifiers are needed and what diagnosis codes to assign can be challenging for surgeons. An area of particular confusion is screening colonoscopies converted to a diagnostic or therapeutic colonoscopy. To complicate the issue, Medicare uses different...
Medical Necessity is not Medical Decision Making
June 1st, 2015 - Codapedia Editor
I can count on two consistent issues in coding audits. Doctors report that their patients are, in general, sicker than patients in other practices. Coders report that their physicians are, in general, worse documenters than physicians in other practices and select codes that are too high based on...
Category of Code Selection
March 17th, 2015 - Codapedia Editor
Does anyone remember the good old days, when you didn't need to know the patient's insurance to select a category of code? Now, correct selection of an E/M category of code requires the clinician and coder to consider: Where the service was performed The status of the patient...
Consult Documentation Guidelines
September 3rd, 2014 - Jeannie Cagle, BSN, RN, CPC
By Jeannie Cagle, BSN, RN, CPC For those practices that bill consultation codes, the guidelines can be confusing. Yet, it is worth taking the time to learn the rules to get the additional reimbursement paid for consultation codes over new patient codes. Remember the following: · ...
Medicare Inpatient only list - online search tool
April 30th, 2014 - Mike Todai
CMS provides Medicare Inpatient list. There are several links Dr. Hirsch has provided to clarify the topic so I will not spend much time to save reader's time. Our recommendation is that hospitals should ask for CPT® / Procedure codes from the physician / physician office. We have built an...
Medicare Inpatient only list - online search tool
April 30th, 2014 - Mike Todai
CMS provides Medicare Inpatient list. There are several links Dr. Hirsch has provided to clarify the topic so I will not spend much time to save reader's time. Our recommendation is that hospitals should ask for CPT® / Procedure codes from the physician / physician office. We have built an...
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...
Bevy of changes make figuring out 2014 Medicare payments more complicated
January 3rd, 2014 - Scott Kraft
Some years, it is relatively simple to project how your Medicare payments will change for the services rendered. When the only factor in Medicare’s complicated payment formula that changes is the conversion factor, the percentage change in your payment is identical to the percentage change in...
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...
Wellness visits for Medicare patients
November 18th, 2013 - Codapedia Editor
Dec 20, 2010 Added Medicare's MLN Matters article as a resource. Hold the champagne--it's true that Health Care Reform added an annual "wellness"visit for every beneficiary, but it's not what you or your doctors think of as an annual exam. In fact, it's has more in common with the...
ICD-10 updates for LCDs, articles due by April 10, 2014
September 10th, 2013 - Scott Kraft
Take out your ICD-10 implementation plan and write down the date of April 10, 2014. That’s the day that CMS has instructed its Medicare Administrative Contractors (MACs) to publish all of the updated local coverage determinations (LCDs) that need to have ICD-10-CM codes replace ICD-9 codes....
Hospice Care
August 28th, 2013 - Codapedia Editor
Patients who sign up with hospice waive their rights to receive Medicare Part B services, and must look to the hospice organization to provide care related to the terminal illness. The hospice provider receives a daily payment to care for the patient on hospice. The patient’s own attending...
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...
Certifying home health services
May 15th, 2013 - Codapedia Editor
Starting January 1,2011 physicians must see and examine a patient when ordering Medicare covered home health care services. This is a condition of the health reform act (Affordable Care Act) passed in the spring of 2010. Prior to certifying the patient's order for HH services, the physician must...
Incident to Services for Medicare Patients
April 24th, 2013 - Codapedia Editor
Incident to services is a Medicare provision which allows physician offices to bill for services provided by a Non-Physician Practitioner or nurse or medical assistant under the physician's provider number. The service is then paid at 100% of the Medicare Fee Schedule. NPPs may bill services under...
Medicare Wellness Visits--update
April 24th, 2013 - Codapedia Editor
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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,...
Three-day Window Rule
April 8th, 2013 - Codapedia Editor
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Medicare Secondary Payer
March 22nd, 2013 - Codapedia Editor
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OIG Work Plan 2012
April 2nd, 2012 - Codapedia Editor
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New ABN form mandatory Nov 2011
March 15th, 2012 - Codapedia Editor
An Advance Beneficiary Notice (ABN) is a written communication given to a patient prior to providing a service that informs the patient that Medicare may not or will not cover the service. It is required when the service is sometimes, but not always, covered. If the service is never covered...
Medicare as a Secondary Payer and Consults
January 10th, 2011 - Codapedia Editor
Now that Medicare doesn't recognize consults (effective 1-1-10), how will we bill for patients who have a commercial insurance as primary, and Medicare as a secondary payer? There are no great options. Options for office “consults” Bill primary with consult codes. Will cross...
No More Consults? CMSs Proposal for 2010
January 30th, 2010 - Codapedia Editor
July, 2010 By now you've seen the headline! CMS proposes to eliminate payment for consults in 2010! Why? How will they pay for the services? First, the AMA develops and owns CPT® codes, and only they can add, delete, or change the definition of CPT® codes. However, Medicare and private...
Fee Schedule 2010 Impact by Specialty
January 30th, 2010 - Codapedia Editor
Elizabeth Woodcock prepared this Excel summary from the Physician Fee Schedule Final Rule, released Friday, October 30, 2009. She graciously shared the file with me, and invited me to post it here. It is in resources. You can access the Final Rule for yourself...
January 30th, 2010 - Codapedia Editor
Updated: Dec 16, 2009 By now, we have all heard that CMS will not pay for consuts starting Jan 1, 2010, but we had lingering questions about how to submit claims. Dec 15, CMS released a transmittal, dated Dec 14, 2009, which answers these questions. The transmittal is attached. For services that...
September 18th, 2009 - Charlene Burgett
In an attempt to make the ABN more understandable for my physicians and staff, I developed this explanatory paper that is specific to our office; however, the basics apply to all offices. Charlene Burgett,MS-HCM,CMA(AAMA),CPC,CCP,CMSCS,CPM Administrator, North Scottsdale Family Medicine POMAA...
Prolonged services for office and outpatient visits
July 31st, 2009 - Codapedia Editor
This is an article describing using prolonged services codes in an office setting. There is a separate article in Codapedia about using prolonged services codes in an inpatient setting. There is an article describing using non-face-to-face codes, as well. Prolonged services codes are add-on...
Prolonged Services in an inpatient setting
July 31st, 2009 - Codapedia Editor
This article will describe the coding for using prolonged services in an inpatient setting. The codes are 99356: Prolonged physician service in the inpatient setting, first hour and 99357 each additional 30 minutes. See the CPT® book for the complete descriptions. These codes are used as add...
Assistant surgeon
July 19th, 2009 - Codapedia Editor
Some surgical procedures may be performed with both a primary surgeon and an assistant surgeon. Insurance companies typically pay 20% to 25% for the assistant. Medicare allows 16% of the full fee payment for the assistant surgeon.
Supervision Requirements for Diagnostic Tests
July 17th, 2009 - Codapedia Editor
Medicare has specific physician supervision requirements for diagnostic tests. Each CPT® code that represents a diagnostic test is given a supervision indicator in the Medicare Fee Schedule. From Chapter 15, of the Medicare Benefit Policy Manual describes these levels of supervision: General...
G0101 Pelvic and breast exam
July 6th, 2009 - Codapedia Editor
Medicare does not pay for routine physical exams annually for patients--a sore spot for Primary Care Providers and Medicare beneficiaries alike. They do pay for an initial Welcome to Medicare visit. (See the Codapedia article about that topic.) Medicare does pay for a screening pelvic and breast...
Nurse visits in provider based clinics
May 27th, 2009 - Codapedia Editor
Question: Can you bill a nurse visit, 99211, to Medicare in a Provider Based Entity? Answer: You may not bill a nurse visit to Part B, for a physician service, but may bill a facility fee for a nurse visit in a PBE. Discussion: Discussion: The payment rules for a free-standing,...
ROS Checklist
April 22nd, 2009 - Rikki Runyon
Review of Systems CHECKLIST: -General- ? Weight loss or gain ? Fatigue ? Fever or chills ? Weakness ? Trouble sleeping ----------------------------------------------------------------------------------- -Skin- ? Rashes ...
Shared services
April 21st, 2009 - Codapedia Editor
The shared services rule is a Medicare rule, which allows a physician and a Non-Physician Practitioner (NPP) to each provide some portion of an Evaluation and Management service, and to bill the service under the physician's NPI. The level of service is based on the documentation provided by both...
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...
Incident to Billing or Incident to Service
April 10th, 2009 - Jeannie Cagle, BSN RN CPC
By Jeannie Cagle, BSN, RN, CPC This question appeared in a recent list serve. My two responses are based upon two different assumptions: (1) both providers are physicians, and (2) one of the providers is not a physician. The principal points are that each physician has a unique National Provider...
E-Prescribing and Medicare Bonus Payments
April 1st, 2009 - Crystal Reeves
By Crystal Reeves, CPC, CMPE Question Our doctors want to begin e-prescribing in order to get the Medicare bonus payment. How much is the bonus payment, and how do we let Medicare know that we are e-prescribing? Answer The Medicare Improvements for Patients and Providers Act of 2008 (MIPPA)...
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...
Can a Physicians Assistant do a consult?
March 9th, 2009 - Codapedia Editor
This question comes up at seminar after seminar. Someone says, "My billing manager told me that PAs (or NPs) can't do consults. Is that true?" It is a half truth. PAs and NPs may perform consults, as long as consults are in their state scope of practice. They may perform consults on...
Locum tenens billing
March 4th, 2009 - Codapedia Editor
The locum tenens rules are Medicare rules that allow for a physician practice to bill for a substitute, temporary physician under the provider number of a physician who has left the practice. The physician must be absent from the practice due to illness, vacation, CME or the physician may...
Advance Beneficiary Notice
March 3rd, 2009 - Codapedia Editor
The Advance Beneficiary Notice (ABN) form was revised by Medicare in April of 2008. There are no longer two forms available, one for lab and one for other services; there is a single form. Starting March 1, 2009, all physicians must use the new form. When completing the ABN, the practice should...
Certification of Home Health Agency Services for Medicare
February 25th, 2009 - Codapedia Editor
In 2001, Medicare added two new HCPCS codes to describe certification and recertification of home health services performed by a physician. A qualified NPP may not provide this service because only a physician may order home health services for a patient. There are two codes, G0179 and G0180,...
PT/OT Therapy caps
January 29th, 2009 - Codapedia Editor
The MedLearn Matters article on PT/OT caps is attached as a resource.
Welcome to Medicare Visit
January 29th, 2009 - Codapedia Editor
Welcome to Medicare Initial Preventive Physical Examination (IPPE) A new benefit under the Medicare Modernization Act Effective date 1-1-05, changes for 2009 Eligibility: Any Medicare beneficiary who enrolls in Medicare on or after January 1, 2005 Time limits: Eligible for benefit in the...

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