The most commonly reported CPT codes are getting a much-needed makeover. Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS, writes about E/M code changes implemented this year and changes for implementation over the next two years.
Healthcare organizations and providers are experiencing a shift in outpatient reimbursement: from fee-for-service to Alternative Payment Models and value-based reimbursement based on quality outcomes.
The most commonly reported CPT codes are getting a much-needed makeover. Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS , writes about E/M code changes implemented this year and changes for implementation over the next two years.
Providers will find significant leeway in how they can report advance care planning (ACP) services for physicians given CMS’ open-ended coding requirements. Review potentially confusing CPT time rules and other obstacles that may be holding back providers from engaging in ACP services.
A spinal fusion is a major surgery used to fuse together two or more vertebrae so they can heal into a single bone. This article breaks down spinal anatomy and simplifies CPT and NCCI guidance for reporting spinal fusions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Yvette DeVay, MHA, CPC, CPMA, CIC, CPC-I, writes that in the 2018 OPPS final rule, CMS removed total knee arthroplasty (TKA) from the inpatient-only (IPO) list, effective January 1, 2018. Although some guidance was provided at the time, providers and physicians alike were left confused with a significant number of questions regarding documentation and inpatient status.
Vestibular migraine is a common visual and neurological disorder that can be difficult to diagnose as symptoms of the disorder resemble those of other conditions such as vestibular neuritis and Meniere’s disorder. In this article, Debbie Jones, CPC , reviews clinical indications of vestibular migraine disorder and CPT coding for diagnostic tests used to assess vestibular functioning.
Providers will find significant leeway in how they can approach and report advance care planning services for physicians given CMS’ open-ended coding requirements, which should push the already strong growth of the codes to new heights.
Hospital coders must develop and adhere to internal E/M coding guidelines and CPT guidance to accurately report visits to the ED. In addition, because ED coding encompasses professional and facility billing, they may need to scour provider documentation to determine the correct E/M service level for both bill types.
Telehealth services are likely to promote health, wellness, and disease management, providing an avenue to offer efficient, high-quality care while supporting value-based care in a cost-effective manner. Although the benefit of telehealth is obvious and its value is continually highlighted by CMS, it appears the services are underutilized.
Anemia is the most common blood disorder, affecting more than 3 million Americans per year, according to the National Heart, Lung, and Blood Institute. In this article, Joel Moorhead, MD, PhD, CPC , reviews documentation and ICD-10-CM coding for anemia.
Wound care coding is frequently a target of payer and Office of Inspector General audits. This article provides coders with step-by-step instructions for interpreting provider documentation and assigning CPT codes for excisional, selective, and non-selective debridement, based on the depth of the tissue removed and the total surface area debrided. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
As outpatient clinical documentation improvement (CDI) programs mature, CDI professionals need to be able to track their progress to ensure the program’s success. Learn how to develop CDI tracking tools to successfully capture coding and billing metrics and justify a CDI program’s effectiveness.
According to the U.S. Department of Health and Human Services, endometriosis affects 11% of women between the ages of 15 and 44. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , writes about diagnosing and treating endometriosis as well as ICD-10-CM and CPT coding for the condition.
CMS recently published One Time Notification Transmittal 2259 and MLN Matters 11168 , which outline changes to the processing of NCCI procedure-to-procedure edits associated with modifiers -59 and -X{EPSU}. Read about these updates and how they will impact CPT coding and for select surgical procedures.
Hospital coders must develop and adhere to internal E/M coding guidelines and CPT guidance to accurately report visits to the ED. Review expert advice on accurate documentation and coding for outpatient ED visits and for developing detailed E/M guidelines. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
In the 2018 OPPS final rule, CMS removed total knee arthroplasty (TKA) from the inpatient-only (IPO) list effective January 1, 2018. Although some guidance was provided at the time, providers and physicians alike were left confused with a significant number of questions regarding documentation and inpatient status
Many outpatient CDI professionals stepped into their roles blind—not knowing where to begin or how to tell if they were successful. However, as programs mature, they need to be able to track their progress for a number of reasons, including focusing physician education and justifying continued funding from organizational leadership.
Coding for knee arthroscopies can be challenging, especially when procedures are performed in multiple compartments of the same knee. Read about anatomy and coding details required to accurately report these procedures.
Outpatient coders and billers must be able to interpret potentially confusing documentation elements for drug administration services and know what to do when key elements, such as infusion time, are missing from an order. Review CMS guidance on the accurate reporting and billing of intravenous drug administration services for calendar year 2019. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
CMS added new guidance to the CPT Manual to clarify imaging documentation for codes that include both procedural and imaging guidance. This article outlines these regulatory changes and implications for outpatient coders and providers.
Prostate cancer is the second most common form of cancer in American men, according to the American Cancer Society. Shelley C. Safian, PhD, RHIA, CCS-P, CPC-I , writes about CPT coding for rectal exams and a new prostate specific antigen (PSA) immunoassay test used to detect early indications of prostate cancer, as well as ICD-10-CM codes used to support medical necessity for these services.
Arthroscopic procedures allow surgeons to use minimally invasive arthroscopic techniques to treat conditions which previously required more intensive, open surgery. Learn about orthopedic anatomy and terminology and CPT guidelines for reporting arthroscopic hip and knee procedures. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Review advice from experts on accurate documentation and CPT coding for chronic care management, knee injection services, and health and behavior assessments.
Modifier -JW is used to describe drug amounts that are discarded and not administered to any patient. This does not reduce the payment for the drugs, so this is an informational modifier, but it is a mandatory modifier.
Pay close attention to new CPT documentation and coding guidance for reporting radiological imaging. For example, a new paragraph titled “Imaging Guidance” in both the surgery and medicine guidelines advises that even when imaging guidance or supervision are included in a surgical procedure code, you must still follow the radiology documentation requirements in the CPT manual.
In 2018, most organizations held the line on coder productivity, according to the results of sister publication HIM Briefings’ 2018 coding productivity survey.
In the current healthcare climate the issue of medical necessity documentation, or lack thereof, is one of the most common reasons for claim denials. Review medical necessity guidance from CMS and learn how to prevent repeated denials due to improper documentation of medical necessity. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The beginning of a new year typically brings new resolutions to deal with weight-related issues. Shelley C. Safian, PhD, RHIA, HCISPP , writes about ICD-10-CM coding for common weight-related diagnoses such as obesity and anorexia, and CPT coding for interventions used to treat them.
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , reviews common CPT and ICD-10-CM coding and documentation errors, such as unbundling, inappropriate modifier usage, and missing information, to help coders reduce their risk from audits.
Even on a small scale, the implementation of an outpatient clinical documentation improvement (CDI) program can be overwhelming. Review advice from CDI specialists on developing successful outpatient CDI programs that facilitate accurate coding and billing.
The ICD-10-CM Manual was recently updated with new codes for peritonitis in association with acute appendicitis and the CPT Manual now includes new codes for gastrostomy tube replacements. Familiarize yourself with these changes to ensure accurate reporting of digestive diagnoses and treatments. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Establishing an outpatient CDI program can have substantial benefits. Recently, an outpatient CDI review project demonstrated there were many documentation improvement opportunities at a large family practice/internal medicine physician clinic.
The 2019 CPT code update includes 19 code additions and three revisions to the cardiovascular section of the CPT Manual. These changes reflect advances in surgical treatment for cardiovascular conditions such as heart failure and aortic stenosis.
A variety of therapeutic services can be used to treat patients suffering from debilitating mental health conditions. Clear up confusion surrounding CPT coding for these initial office visits, psychiatric diagnostic evaluations, and psychotherapy visits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Reporting and billing hospital observation services can be confusing, particularly when the observation stay lasts more than one day. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , writes about CPT coding for observation services based on time and the key components of the history, exam, and medical decision making of a patient.
Take cues from the revised NCCI Policy Manual for Medicare Services to polish your coding and billing efforts in 2019 and avoid common infractions tied to modifier -50 (bilateral procedure).
The AMA updated the cardiovascular section of the 2019 CPT Manual to reflect advances in surgical treatment for cardiovascular conditions such as heart failure and aortic stenosis. Read about new and revised codes for the implantation and removal of leadless pacemakers, cardiac rhythm monitors, and other surgical devices commonly used to treat chronic heart conditions. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The 2019 CPT code update will impact reporting for dermatologic biopsies. Shelley C. Safian, PhD, RHIA, HCISPP, CCS-P, COC, CPC-I , reviews updated reporting guidance and CPT codes for these common types of biopsies.
CMS hit the brakes on making imminent changes to the oft-used E/M code set that’s tied to billions of dollars in medical practice revenue. Review updates to E/M payment and documentation requirements effective January 1 and the extensive changes planned for implementation in 2021 under the 2019 Medicare Physician Fee Schedule final rule.
Along with E/M changes for 2019 and beyond , the 2019 Medicare Physician Fee Schedule final rule contains a plethora of regulations impacting reimbursement, including new modifiers for therapists.
Despite facing potential lawsuits and political opposition, CMS finalized some of its most controversial proposals in the 2019 OPPS final rule by implementing several site-neutral payment policies and 340B drug payment reductions.
Outpatient procedures involving anesthesia should be reported using five-digit CPT codes as well as applicable hospital modifiers. Review types of anesthesia administration and documentation elements required for accurate code assignment. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
It's been more than three years since CMS introduced a subset of modifiers it wants providers to report instead of modifier -59 (distinct procedural service), but they're still optional as barely any new guidance has been released.
Beginning in 2018, total knee arthroplasty (TKA) was removed from the Inpatient Only List and assigned a comprehensive APC payment. Outpatient coders need to ensure they are assigning the correct CPT codes for TKA to reduce their hospital’s risk of audits.
Coders must have a solid understanding of complex terminology and CPT and ICD-10-CM coding guidelines to select the most specific codes for traumatic fractures and their treatments. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
The CMS risk adjustment model uses Hierarchical Condition Categories (HCC) to calculate risk scores based on ICD-10 diagnoses. Review HCC coding do’s and don’ts to help your facility manage risk effectively, enhance shared savings, and provide patient-centered care.
The death of one twin in utero complicates oversight of a multifetal pregnancy. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , reviews symptoms of vanishing twin syndrome and ICD-10-CM coding for continuing pregnancy after intrauterine death .
Remittance processing and appeals are integral parts of the revenue cycle. When facilities submit a claim to Medicare, the hope is that the claim will be paid in full and in a timely manner, but that does not always happen.
In the 2019 OPPS final rule, released November 2, CMS implemented several site-neutral payment policies, though the agency did delay or shelve other proposals due to stakeholder feedback.
The FY 2019 ICD-10-CM update includes 54 code additions, three deletions, and 87 revisions to Chapter 19 of the ICD-10-CM Manual , “Injuries, Poisonings, and Certain Other Consequences of External Causes.” Review updated codes and guidelines for reporting burns, infections and sepsis following a procedure, drug abuse, and human trafficking. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Coding and documentation teams can replicate an organization’s overall denial avoidance and management program by scaling it to the scope of denials for which they are responsible. Lynette Kramer, MA, RHIA , outlines a four-step process that coding teams can use to monitor claim data and establish accountability for denials.
According to the National Center for Chronic Diseases Prevention and Health Promotion, an estimated 5.7 million adults throughout the U.S. have heart failure. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, writes about ICD-10-CM coding for heart failure diagnoses and CPT coding for procedures used to treat the disease.
Before radiation therapy can be administered, several steps must be taken prepare the patient for treatment. Review CPT coding and documentation for the first two steps in the process: the initial consultation and preparation for radiation treatment. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Patients determined to have a tubo-ovarian abscess (TOA) require immediate and aggressive surgical therapy. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , reviews clinical documentation and ICD-10-CM coding for TOAs as well as CPT coding for surgical interventions used to treat them.
Modifier -25 is frequently a target of payer and Office of Inspector General audits. Susan E. Garrison, CHCA, CPC, CPC-H, reviews CMS and NCCI guidance for reporting modifier -25.
Developing an outpatient CDI program isn't just about metrics--departments needs to consider how to engage providers and interact with other teams to be truly effective.
As coders mark the third anniversary this October of the U.S. implementation of ICD-10, its newly minted successor is waiting in the wings, nearly ready for adoption.
It's been more than three years since CMS introduced a subset of modifiers it wants providers to report instead of modifier -59 (distinct procedural service), but they're still optional as barely any new guidance has been released.
CMS recently released updated guidance on billing intensity-modulated radiation therapy (IMRT) after an OIG audit found a 100% error rate in billing certain IMRT planning services.
Peggy S. Blue, MPH, CPC, CCS-P, CEMC , reviews the key characteristics of physician visits administered to patients in skilled nursing facilities and E/M coding for these services.
Coding leadership can assist the chargemaster team by providing input, preparing appeals, and tracking coding-related denials. Rose T. Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS , describes how to effectively work with a team of coders to combat continued denials.
Medicare guidelines for reporting arthroscopic shoulder surgeries have changed significantly over the past decade. Review updated guidance and CPT coding for SLAP repairs as well as biceps tenotomy and tenodesis procedures to reduce audit risk. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Age-related macular degeneration (AMD) is a leading cause of vision loss among people age 50 and older, according to the National Eye Institute. Debbie Jones, CPC, CCA , reviews ICD-10-CM coding for AMD and CPT coding for treatments used to slow the disease’s progression.
A nine-month audit conducted by a CDI specialist at a family practice and internal medicine clinic revealed 1,353 coding errors on physician-coded claims for outpatient office visits. Tammy Trombley, RHIT, CDIP, CCDS , reviews findings from this 2017 audit and discusses implications for risk-adjustment coding.
According to the American Academy of Orthopedic Surgeons, in 2013, 2 million people in the U.S. saw a physician for a rotator cuff problem. Review shoulder anatomy and CPT coding for rotator cuff repairs to improve coding accuracy. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Modifiers -25 and -27 are used in the outpatient facility setting on E/M services. Learn more about how these modifiers should be applied in accordance with coding and Medicare guidelines.
To effectively report opioid use, abuse, and dependence, coding and billing professionals must be able to recognize symptoms of these disorders and interpret detailed ICD-10-CM guidelines. Additionally, they must be able to identify complications associated with opioid misuse and overdose.
E/M code assignment for hospital admissions based solely on the provider’s documentation of face-to-face-time spent with a patient can be confusing and requires a detailed understanding of CPT guidelines. Lori-Lynne A. Webb , CPC, CCS-P, CCP, CHDA, COBGC , reviews reporting requirements for E/M visit levels based on the provider’s documentation of time and CPT coding for hospital admissions.
In 2017, the U.S. Department of Health and Human Services (HHS) declared a nationwide public health emergency to address the opioid crisis, investing almost $900 million in opioid-specific funding to support treatment and recovery services. Learn about the epidemic and review ICD-10-CM coding and guidelines for reporting opioid use, abuse, dependence, and overdoses.
Continuing with numerous requests for comment in last year’s OPPS proposed rule, CMS is once again asking stakeholders for feedback on a variety of issues for potential future rulemaking. Review OPPS proposals for quality measure changes and policies aimed at improving interoperability and the electronic exchange of information between providers.
The 2019 Medicare Physician Fee Schedule (MPFS) proposed rule includes significant potential updates to E/M coding and reporting. Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS , reviews the proposed changes and their potential impact on coding and billing for office visits and other outpatient services in 2019.
A common error and audit finding affecting providers is the lack of a physician order or physician signatures on medical documentation. Kimberly A. H. Baker, JD, CPC , reviews CMS guidance for physician signatures on medical documentation.
Back in January, I wrote an article regarding E/M codes and the need for changes to the 1995 and 1997 E/M documentation guidelines. In that article, I suggested making E/M codes for office visits solely time-based to simplify the reporting of these very subjective codes. Little did I know that this is what CMS would propose months later.
CMS’ 2019 OPPS proposed rule, released in late July, continues the agency’s efforts to enforce site-neutral payments and reduce drug payments by introducing policies to reduce reimbursement for hospital outpatient clinic visits at off-campus, provider-based departments.
ICD-10-CM and CPT coding for glaucoma and retinal detachment requires a detailed understanding of coding guidelines as well as ocular anatomy and terminology. Explore the anatomy of the eye and review coding guidance for conditions that affect our view of the outside world. Note : To access this article, you must first register here if you do not have a paid subscription.
Along with quality measure removals in the 2018 OPPS and MPFS final rules, CMS has continued to propose additional removals in the 2019 proposed rules. In addition, the agency is proposing to add to its ability to remove quality measures in the future.
Continuing with numerous specific requests for comment in last year’s OPPS proposed rule, CMS is once again asking stakeholders for feedback on a variety of issues for the 2019 OPPS proposed rule for future potential rulemaking. You may submit comments to the agency until September 24, 2018.
Hypertension, or high blood pressure, is not easily diagnosed and brings added risk factors to pregnancy oversight. Lori-Lynne Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, reviews ICD-10-CM coding for hypertension during pregnancy and related complications.
To succeed in a modern health information management (HIM) environment, coding departments need efficient coding specialists and knowledgeable management to monitor coder performance and provide feedback. Review expert guidance on hiring staff and determining work flow to improve the organizational structure of your coding department.
This second article in a series reviews common procedures used to isolate back pain and reduce inflammation including nerve block injections, facet joint injections, and facet denervation. CPT coding for these procedures is complex and requires a detailed understanding of spinal anatomy and terminology as well as coding guidelines. Note : To access this article, you must first register here if you do not have a paid subscription.
Coding professionals will need to familiarize themselves with 2019 updates to the ICD-10-CM Manual , including significant changes to chapter two for neoplasms and chapter 5 for mental disorders. Shannon McCall, RHIA, CCS, CCS-P, CPC, CEMC, CRC, CCDS , summarizes important 2019 ICD-10-CM updates , which will impact payment for claims submitted on or after October 1.
In the April 2018 OPPS update transmittal, CMS announced new HCPCS code C9749 (repair of nasal vestibular lateral wall stenosis with implant[s]), effective April 1, 2018.
Many HIM directors find that managing the coding team requires a different type of focus than other functions within the department. This may be true because coding professionals have advanced education, prefer a quiet work environment, and require less direction.
The fiscal year (FY) 2019 ICD-10-CM code update, released on June 11, includes 279 code additions, 143 revisions, and 51 invalidations. The number of changes is significantly less than the past two years, which makes me think we are getting back to the “norm” of expected yearly changes.
Cornelia de Lange syndrome is a genetic disease that could be misdiagnosed due to its rarity. Yvette DeVay, MHA, CPC, CPMA, CIC, CPC-I , reviews symptoms, procedural treatments, and ICD-10-CM coding for the condition.
Understanding when and how to report hospital modifiers is critical to ensuring compliant billing. Review CPT guidelines for modifiers -25, -50, and -59, as well as case studies and denial numbers by specialty, to reduce your risk from audits. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Provider documentation must meet required standards to support the level of care provided. Rose Dunn, MBA, RHIA, CPA/CGMA, FACHE, FHFMA, CHPS , reviews payer guidelines and medical necessity requirements under Medicare for services performed in the outpatient setting.
Cognitive impairment ranges from mild to severe and can impact a person’s ability to perform everyday functions such as talking, remembering, and comprehending information. Debbie Jones, CPC, CCA , reviews CPT and ICD-10-CM coding, and care planning for patients living with cognitive impairment.
Cancer is the second most common form of death in the U.S., according to the Centers for Disease Control. To accurately report CPT and ICD-10-CM codes for skin and breast cancer, coders need a thorough understanding of symptoms of malignancies and treatments used to prevent them from spreading. Note : To access this free article, make sure you first register here if you do not have a paid subscription.
Hospital systems need to be watchful for CMS proposals that will impact payment for drugs and drug therapies in 2019 and beyond. Jugna Shah, MPH, reviews the potential implications of recent CMS actions, such as the publication of the 2019 IPPS proposed rule and the overhaul of 340B drug payment program.
Predicting CMS policies can be a foolhardy exercise, especially with a relatively new administration and frequent turnover at the highest levels of HHS over the last year. But it’s safe to say drug payment policy has been and will continue to be a focus of the current regime.
Healthcare providers are often confused about what a commercial or managed care payer would want in order to approve the claim. Much of this confusion comes from the timing of requirements to ensure reimbursement.
