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.
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.
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.
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.
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.
A July 2018 update to the OPPS clarifies that coders can report HCPCS code C9749 for an inherently bilateral procedure with modifiers -73 or -74 to indicate that the procedure was unilateral. Debbie Mackaman, RHIA, CPCO, CCDS, unpacks this seemingly contradictory guidance and addresses implications for coding and billing professionals.
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.
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.
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.
A recent report from the Office of Inspector General focuses on improper payments for specimen validity tests billed in combination with urine drug tests. Yvette DeVay, MHA, CPC, CPMA, CIC, CPC-I, reviews Medicare instructions and coding guidance for presumptive and definitive drug testing.
According to the National Institute of Diabetes and Digestive and Kidney Diseases (NIDDK), it is estimated that more than half a million people in the U.S. have Crohn’s disease. For unknown reasons, the disease has become more widespread in both the U.S. and other parts of the world.
Medical necessity documentation, or lack thereof, is one of the most common reasons for claim denials. This article describes how medical necessity impacts third-party payers and those who work in billing and reimbursement services.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS , writes about discussions at the 2017 AMA CPT Symposium that could impact coders, including issues with the Table of Risk for E/M office visit codes and suggestions for E/M guideline revisions. This article is part two in a series.
One of the most memorable sessions at the AMA CPT Symposium in November 2017 involved an impromptu open mic feedback session facilitated by CMS’ Marge Watchorn, deputy director of the Division of Practitioner Services. The focus of this session was the applicability of the current CMS documentation guidelines for E/M services.
In the current healthcare climate, the issue of medical necessity documentation, or lack thereof, is one of the most common reasons for claim denials. For a service to be considered medically necessary (by a third-party payer), it must be considered a reasonable and necessary service to diagnose and/or treat a patient’s current and/or chronic medical condition.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS , writes about discussions at the AMA CPT Symposium that could impact coders, including the need for updates to CMS’ E/M Documentation Guidelines and how medical decision making is used as a key component for E/M reporting.
Bundled Payments for Care Improvement Advanced, a new voluntary bundled payment model launched by CMS in January, includes 32 clinical episodes encompassing both inpatient admissions and outpatient procedures. Yvette DeVay, MHA, CPC, CPMA, CIC, CPC-I , writes about participation criteria, payment calculations, and quality measures for this program.
In recent years, numerous pieces of legislation have been passed to limit healthcare spending, combat losses due to fraud, and ensure that dollars are being spent on quality care. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP , describes different watchdog programs created to promote billing compliance and quality of care.
In this article, Valerie A. Rinkle, MPA, offers guidance regarding the 340B drug discount program. She provides tips for accurate documentation of drug purchases and reviews frequently asked questions about billing for 340B-acquired drugs in 2018.
Complying with healthcare regulations within a coding department or physician practice involves promoting a positive attitude toward activities such as self-monitoring and staying up-to-date with healthcare regulations. Follow these steps to adhere to sound business ethics and set expectations for behavior across an organization. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Updates to the 2018 CPT Manual , set to go into effect January 1, include several additions, revisions, and deletions to E/M and anesthesia procedural code sets. Familiarize yourself with these coding changes to aid in accurate reporting and prevent disruptions to the claims process. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
HCCs aren’t new, but for many organizations, their impact hasn’t been apparent until recently. Organizations must educate staff on HCCs to ensure success under reimbursement methodologies such as the Quality Payment Program and Merit-based Incentive Payment System reimbursement.
November, a month associated with the pleasure of eating, is also Stomach Cancer Awareness Month. In this article, Yvette M DeVay, MHA, CPC, CPMA, CIC, CPC-I, describes signs and symptoms of stomach cancer, and outlines best practices when assigning diagnostic and procedural codes for this disease.
In order to accurately code for complex diseases and procedures of the brain, spinal cord, and sense organs, coders need a basic understanding of nervous system functionality. This article provides detailed information on nervous system anatomy and terminology, common brain and nervous system disorders, and recently introduced 2018 ICD-10-CM codes related to nervous system conditions.
Ovarian cysts may develop at any point in a woman's life and frequently occur with other medical diseases. In this article, Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, details best practices when assigning ICD-10-CM/CPT codes for ovarian cyst diagnoses and procedures.
In July, Utah pain doctor Jahan Imani, MD, and Intermountain Medical Management, P.C., entered into a nearly $400,000 settlement with the OIG to resolve allegations that Imani’s practice submitted false or fraudulent claims due to improper modifier use for payment by improperly using modifier -59 with HCPCS code G0431.
Documentation is crucial for the development of data reflecting the healthcare needs of domestic violence victims. Yvette DeVay, MHA, CPMA, CPC, CIC, CPC-I , explains how to properly screen for and code incidents of domestic violence.
E/M services are some of the most frequently used CPT codes, and they are also some of the most frequent examples of incorrect coding. One of the problem areas in selecting the proper E/M code is distinguishing between new and established patients. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
The Quality Payment Program proposed rule seems to bring relief to providers anticipating escalation of Medicare Access and CHIP Reauthorization Act (MACRA) requirements, but there are a plethora of reasons for coding professionals to start adapting their workflow for MACRA now. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
As CMS and third-party payers have looked for ways to treat patients in the outpatient setting and reduce inpatient volumes, CMS has used the 2-midnight rule, in addition to other methods, to treat patients as outpatients or in observation whenever possible.
CMS Special Edition article 1609 was released in April to clarify CMS’ policy on prolonged drug and biological infusions using an external pump. Valerie A. Rinkle, MPA , breaks down that article and discusses its billing and reimbursement implications in the first of this two-part series.
In the second part of a two-part series on SE1609, Valerie A. Rinkle, MPA , distinguishes between CPT code 96416 and HCPCS code G0498 for billing and reimbursement purposes while outlining how practices can achieve compliance with CMS’ current external pump policy.
CMS released the fiscal year 2018 IPPS proposed rule in April, and with it came a bevy of new potential ICD-10-CM codes. The update includes a total of 406 proposed new, revised, and deleted codes to be implemented October 1, 2017.
HCCs are the basis for risk adjustments for reimbursement models like Medicare Advantage, accountable care organizations, and other value-based purchasing measures such as Medicare Spending Per Beneficiary. Poor understanding and application of HCCs mean that a hospital’s patients may be much sicker in reality than they appear to be on paper, and that will hit reimbursement hard.
The human eye may be small, but it’s one of the most complex organ systems in the body. Review the anatomy of the eye and how to code for conditions affecting the system, including new details for 2017.
The 2017 ICD-10-CM updates included a significant number of additions to digestive system diagnoses, especially codes for pancreatitis and intestinal infections. These codes are largely focused in the lower gastrointestinal tract, and a review of the anatomy of this body system could help improve accurate documentation interpretation and code selection.
Coders have likely noticed that the 2017 CPT Manual features big changes for reporting moderate sedation. Adrienne Commeree, CPC, CPMA, CCS, CEMC, CPIP, writes about how to define moderate sedation and includes tips on reporting the new codes appropriately.
Coding managers cannot always monitor every guideline update or coding-related issue targeted by the Office of Inspector General. Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, reviews what a coding manager can do during a coding audit and how to implement a plan.
Complex chronic care management services can be challenging to accurately tabulate and report. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about how billers and coders can work with providers to report them accurately.
Many coders may know that the human body contains 206 bones, but they may not realize that more than 10% of them are in the cranium. In addition to reviewing skull anatomy, examine common ICD-10-CM codes for skull conditions.
The 2017 CPT update didn’t include a huge amount of changes, but new codes have replaced the previous ones for dialysis circuit coding. Stacie L. Buck, RHIA, CCS-P, CIRCC, RCC, reviews the new codes and what services are included in each.
Coders have many more options to report diagnoses of the foot in ICD-10-CM, with the ability to include laterality, location, and other details related to the injury. Review the bones of the feet and tips for additional documentation details to note when choosing codes for foot fractures.
The shoulder girdle has the widest and most varied range of motion of any joint in the human body. That also makes it one of the most unstable. Read about the anatomy of the shoulder and which coding options exist for procedures of the shoulder.
Chronic care management codes were adopted by CMS in 2015, but relatively few providers use them. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about the criteria needed to code and bill these services, as well as how coders can work with providers to ensure documentation supports the codes.
Human papillomavirus is the most common sexually transmitted infection in the U.S. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, reviews how to report vaccinations for the virus and how coverage policies by differ by carrier. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, delves into chapter-specific guidance included in the updated 2017 ICD-10-CM guidelines, including changes for diabetes, hypertension, pressure ulcers, and more.
Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, continues her review of the updated 2017 ICD-10-CM guidelines by explaining how changes to sections for laterality and non-provider documentation will impact coders and physicians. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
Updated ICD-10-CM guidelines, effective October 1, could cause confusion for some coders. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CRC, CCDS, looks at how changes to reporting linking conditions measure up to previous guidance.
Choosing an E/M level code depends on three components—history, exam, and medical decision-making. History itself has four further components that coders will need to look for in physician documentation. Review what comprises these components to aid in choosing the correct levels.
Obesity is a condition that can complicate coding for other diagnoses in a patient’s record. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC, CDIP, writes about how to report BMI and what must be documented in order to link it with other conditions.
Which services should clinical documentation improvement (CDI) specialists target in outpatient facilities? Anny Pang Yuen, RHIA, CCS, CCDS, CDIP , writes about how outpatient CDI differs from inpatient CDI and how it can be applied in hospitals or physician practices.
The 2016 CPT® code update may have been relatively small compared to previous years, but the urinary and genital system sections did receive numerous changes to align them with other sections of the code book.
CMS administers the Medicare program and it is currently the single largest payer for healthcare in the United States. Medicare Part A, B, C, and D, all encompass a wide variety of services, all of which providers need to understand to determine which services are covered for patients.
Post-traumatic stress disorder isn’t only reported for military personnel. Shelley C. Safian, PhD, RHIA, CCS-P, COC, CPC-I, AHIMA-approved ICD-10-CM/PCS trainer, writes about when PTSD may be reported and which diagnosis and procedures codes should be included.
The AMA introduced new CPT codes for 2016 to report intracranial therapeutic interventions. Stacie L. Buck, RHIA, CCS-P, CIRCC, RCC, reviews the changes and provides examples on how to use them in a variety of procedures.
Perhaps recognizing the massive undertaking for coding and HIM departments in 2015 with the implementation of ICD-10, the latest CPT® update includes a relatively small 367 changes for 2016. Shannon E. McCall, RHIA, CCS, CCS-P, CPC, CPC-I, CEMC, CCDS, and Peggy Blue, MPH, CPC, CEMC, CCS-P, review updates to the digestive system and E/M codes.
Before the new year begins, Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, recommends taking a look at post-implementation risks CMS and third-party payers have identified. She also offers solutions on auditing and reviewing these risks. Note: To access this free article, make sure you first register here if you do not have a paid subscription. Once you have set up your free registration, you can log in and access this article by clicking here.
Physician office coders are likely familiar with coding for x-ray procedures, but may not have much experience coding ultrasound. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, and ICD-10-CM/PCS trainer, reviews how ultrasound procedure codes are categorized and offers tips on reporting them in office settings.
Primary care providers see patients for a wide variety of conditions, meaning coders in those settings may have to learn many of the new concepts and terms in ICD-10-CM. Annie Boynton, BS, RHIT, CPCO, CCS, CPC, CCS-P, COC, CPC-P, CPC-I, and Rhonda Buckholtz, CPC, CPC-I, CPMA, CRC, CHPSE, CGSC, CENTC, COBGC, CPEDC, discuss three common conditions seen in these settings and what information coders will need to look for in documentation to code them in ICD-10-CM.
Nearly 30% of Medicare patients are enrolled in Medicare Advantage (MA) programs, which come with specific coding and documentation challenges. Elaine King, MHS, RHIA, CHP, CHDA, CDIP, FAHIMA, and Bonnie S. Cassidy, MPA, RHIA, FAHIMA, FHIMSS, highlight key requirements for reporting diagnoses that map to Hierarchical Condition Category codes, the basis of MA plans.
Evaluation and management (E/M) services are one of the top areas of review by federal auditors. Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, COBGC , writes about common errors found in audits and how providers can take steps to correct them.
Hierarchical Condition Category (HCC) coding may be a foreign concept for some coders, but making sure documentation for Medicare Advantage patients supports it can be critical. Holly J. Cassano, CPC , discusses what criteria needs to be met for complete documentation.
While the digestive and integumentary sections had extensive edits in the latest CPT ® update, many sections were left relatively unchanged. Joanne Schade-Boyce, BSDH, MS, CPC, ACS , and Denise Williams, RN, CPC-H, review which sections only had minor updates and take a closer look at evaluation and management and chemodenervation changes in the 2014 CPT Manual.
The number of patients using Medicare Advantage (MA) is rapidly growing, making Hierarchical Condition Categories (HCCs) an increasingly important concept for revenue cycle staff to understand in order to guarantee reimbursement.
Coders select E/M levels based on criteria developed by their organization. CMS has proposed a significant change to E/M coding-replacing the current 20 E/M levels for new patients, existing patients, and ED visits with three G codes-but that change would only apply to Medicare patients and only to the facility side.
Coders use the same CPT ® codes to report outpatient services whether they are coding physician or facility services. Jaci Johnson, CPC,CPC-H,CPMA,CEMC,CPC- I, and Judy Wilson, CPC, CPC-H, CPCO, CPC-P, CPPM, CPCI, CANPC, CMRS, examine the similarities and differences between coding in the two settings.
Radiation oncology uses high-energy radiation to shrink or kill tumors or cancer cells with minimal harmful effects to healthy surrounding cells. To correctly code for radiation oncology services, coders need to understand the various elements of the treatment.
In the coding world, it’s a never-ending clash that can cause compliance concerns—facility vs. professional. Kimberly Anderwood Hoy, JD, CPC , and Peggy Blue, MPH, CPC, CCS-P, explain how coders in each setting use different codes for the exact same services based on the payment systems, the rules, and how each setting applies those rules.
The biggest operational change for outpatient facilities for 2013 does not appear in the 2013 OPPS final rule. Instead, CMS announced changes to reporting therapy services in the 2013 Medicare Physician Fee Schedule (MPFS) final rule.
Misusing modifier -25 (significant, separately identifiable evaluation and management (E/M) service by the same physician on the same day of the procedure or other service) can be an expensive proposition. Sarah L. Goodman, MBA, CHCAF, CPC-H, CCP, FCS, and Debbie Mackaman, RHIA, CHCO, explain how to determine when an E/M service is significant and separately identifiable.
Misusing modifier -25 (significant, separately identifiable E/M service by the same physician on the same day of the procedure or other service) can be an expensive proposition. Just ask Georgia Cancer Specialists I, a leading oncology practice in Atlanta.
The rules for coding for facilities and physicians are basically the same for most services, but coders follow different rules for appending certain modifiers. Christi Sarasin, CCS, CCDS, CPC-H, FCS , Kimberly Anderwood Hoy, JD, CPC , and Peggy Blue, MPH, CPC, CCS-P, separate physician and facility rules for using modifiers -26, -TC, and -79.
Medicare Advantage plans rely on the Hierarchical Condition Categories (HCC) system for reimbursement. HCC payments are linked to the individual health risk profiles for the members in the plan. MA Plans use ICD-9-CM codes as the primary indicators of each member’s health status. Therefore, it is essential for MA plans to make sure that providers capture the complete diagnostic profile of patients through accurate and complete physician coding. Holly J. Cassano, CPC, explains why coders need to have a complete understanding of the HCC process and risk adjustment, as well as the effects on the provider, the member, the MA plan, and overall reimbursement.