Modifier assignment can be a confusing task, and that work is sometimes made more difficult by encountering a set of modifiers which apply to the same circumstance with only one differentiating factor. A review of some of these modifiers, including modifiers -PO, -PN, -73, and -74, can be essential for accurate claims submissions. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
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 final 2018 ICD-10-CM codes on its website on June 13, and the release contained more code changes than expected following a preview of the new code set in April’s 2018 IPPS proposed rule.
CMS released a change request May 30 describing modifications which will be implemented in the July 2017 quarterly update to the OPPS. These changes include new ophthalmologic and maternal care codes as well as a handful of new drug codes.
There is an extensive list of coverage requirements that must be met to furnish outpatient services to Medicare beneficiaries. Gina M. Reese, RN, JD, CPHRM , discusses some of the trickier issues that facilities will need to audit more carefully while monitoring for compliance in provider-based departments.
The Ochsner Health System in Louisiana revolutionized the way its clinical documentation excellence (CDE) team captures annual hierarchical condition categories for all patients across its vast system. Now, Ochsner can serve as a case study to educate others on how to create an outpatient focus on CDI in an increasingly risk-adjusted world.
May was a busy month for telehealth in the political world on both the federal and state levels. This action serves as a reminder that expanded access will mean an increase in telehealth coding, but navigating eligibility requirements and coding regulations can be a challenge. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
CMS issued a change request to provide guidance to Medicare Administrative Contractors on the use of a new modifier to append to claims for dialysis treatments for end-stage renal disease exceeding the 13 or 14 monthly allowable treatments.
Traditionally, the OPPS rulemaking cycle has been the main vehicle for changes to outpatient coding and billing regulations and policy that hospitals need to pay attention to. But Jugna Shah, MPH , writes that, increasingly, CMS has been introducing or discussing changes relevant to outpatient hospitals beyond the scope of the OPPS rules.
Alcohol and Other Drug-Related Birth Defects Awareness Week began on Mother’s Day and aimed to raise awareness of the dangers of substance abuse during pregnancy. In honor of this awareness week, Yvette DeVay, MHA, CPC, CIC, CPC-I , discusses fetal alcohol syndrome disorders and ICD-10-CM coding for the condition.
Podiatry coding can become complicated quickly, as a number of procedures can be performed on the same site or region of the foot. This means codes could easily run into NCCI edits or denials. One way to ensure physicians are reimbursed properly for provided services is to review NCCI edits pertaining to podiatry.
Q: What is the best way to document time spent by physicians performing procedures? The CPT® codes state a vague time amount but the doctors struggle with this.
Coding plays a large role in claims and therefore is a key factor in reimbursement compliance. As such, coders have a responsibility to be as accurate and up-to-date on coding practices as possible. Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS , explores some of the organizations and regulatory bodies available to assist coders.
Wound care can be messy, but reimbursement and billing for wound care does not need to be as troublesome if coding and documentation are done correctly. One of the bedrocks in billing for wound care is ensuring medical necessity, and there are a few tricks and standards to learn about medical necessity in order to stay compliant. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
Q: What are the documentation requirements for a continuous infusion for an observation patient, especially spanning the midnight hour? We often see rate change or rate verification notations during continuously running infusions, but would a start and stop time be required or expected for each bag change?
CMS released a change request April 28 which provides guidance for Medicare Administrative Contractors on how to ensure accurate program payment for moderate sedation services provided as part of screening colonoscopies.
As physicians and society debate the rising incidence and devastating effects of opioid dependency, neonatal abstinence syndrome, and the use and abuse of other mood-altering chemicals, James Kennedy, MD, CCS, CDIP , explains how providers must partner together to define, diagnose, document, and report drug-related events so that ICD-10-CM-dependent administrative data can accurately measure its epidemiology, responses to treatment, and consequences.
Q: When reporting multiple separate infusions of the same substance or drug provided through the same IV site during one visit, should we add up the total time and then report the appropriate codes?
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.
CMS released the fiscal year 2018 IPPS proposed rule April 14, and with it came a bevy of new potential ICD-10-CM codes. Explore the new additions to the ophthalmologic, non-pressure chronic ulcer, maternity and external cause codes ahead of implementation October 1.
April marks sexually transmitted infections month, and Peggy S. Blue, MPH, CPC, CCS-P, CEMC , gets in the spirit by breaking down the staging, diagnosis, and treatment of syphilis before examining how to code the disease in ICD-10-CM. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
CMS released four new resources in early April on the Merit-based Incentive Payment System, one of two new payment options under the Quality Payment Program initiative created by the Medicare Access and CHIP Reauthorization Act.
Audited hospitals generally applied modifier -59 (distinct procedural service) incorrectly when billing for outpatient right heart catheterizations and heart biopsies provided during the same encounter, leading to overpayments totaling approximately $7.6 million, according to a March report from the Office of Inspector General.
Rose T. Dunn, MBA, RHIA, CPA, FACHE, FHFMA, CHPS, discusses the use of unspecified codes after the ICD-10-CM grace period and advises providers on how to decrease the use of those codes.
A benefit of the switch to ICD-10-CM is the ability to be as specific as possible about a patient’s condition, but the downside of this is that it can make coding fractures time-consuming and confusing. Knowledge of bone anatomy and how fracture codes work is therefore an invaluable asset in fracture coding.
Q: The CPT Assistant advice on how to apply modifier -59 to CPT code 29874 (knee arthroscopy with removal of loose/foreign body) seems to conflict with NCCI edits. Do the NCCI edits override the advice in CPT Assistant ?
Accurate clinical documentation is the bedrock of the legal medical record, billing, and coding. It is also the most complex and vulnerable part of revenue cycle because independent providers must document according to intricate and sometimes vague rules.
Q: We have trouble billing multiple units of injections and infusions – mostly CPT add-on codes 96375 and 96376–that are done during observation stays and exceed the medically unlikely edits number. What is the correct way to bill these and get paid?
CMS released a new educational initiative , Connected Care , on March 15 to help raise awareness of the benefits of chronic care management services, as Medicare has recently added and started paying for these services.
Glands located throughout the body are responsible producing hormones and releasing chemicals into the bloodstream as part of the endocrine system. These glands help maintain many important purposes of the body, including metabolism, growth, and reproductive functions. Note: To access this free article, make sure you first register here if you do not have a paid subscription.
In the second part of this two-part series on the Merit-based Incentive Payment System (MIPS), dive deeper into the four performance categories, their requirements, and their scoring parameters for the first year of MIPS reporting. This article also gives readers tips on what clinicians need to do to prepare for and participate in MIPS in 2017.
In the first part of a two-part series on the Merit-based Incentive Payment System (MIPS), discover the basics of the MIPS program, understand who is eligible for 2017 participation, and navigate the scoring system for the first year of reporting.
The intersection of CMS’ packaged payment policy and the increasing volume of Medically Unlikely Edits (MUE) can be likened to a car crash waiting to happen. Hospitals are having valid, medically necessary claim lines denied – including charges and units below MUE limits. Providers can help stop the crash by ensuring their claims, CPT coding, medical necessity, and the units are all correct.
With a new year underway, providers likely need to get a handle on some key new modifiers, as well as important changes to an existing modifier and the deletion of a modifier that previously raised a lot of questions and operational concerns.
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.
Q: Facilities often have two charges for services performed in an operating room (OR) suite. For example, a facility performs a colonoscopy and an esophagogastroduodenoscopy, which took a total of 20 minutes in the procedure room. The facility charged two set-up fees plus an additional five minutes of OR time. Would this be considered a duplicate charge?
The ICD-10 Coordination and Maintenance Committee will meet March 7-8 to discuss new conditions, procedures, and expanded details that could appear in a future update of the code set.
Inpatient coding departments are likely familiar with integrating clinical documentation improvement (CDI) specialists into their processes. Crystal Stalter, CPC, CCS-P, CDIP, looks at how CDI techniques can benefit outpatient settings and what services and codes facilities should target.
The codes in ICD-10-CM Chapter 13, Diseases of the Musculoskeletal System and Connective Tissue, cover diagnoses for conditions throughout the body. Due to the wide scope of conditions in the chapter, it had extensive updates for 2017. Review some of the most significant changes and the details required to accurately report the codes.
Radiation oncology services billed to CMS had a 9.6% improper payment rate in 2015, leading to Medicare improperly paying $137 million for these services, according to a study reported in the January 2016 Medicare Quarterly Compliance Newsletter .
Lori-Lynne A. Webb, CPC, CCS-P, CCP, CHDA, CDIP, COBGC, writes about the transition of the CPT code for reporting ablation of uterine fibroid tumors from a Category III to Category I code and the impact that could have on coding and billing.
Q: We have claims that are hitting an edit between a procedure HCPCS code and the new codes for moderate sedation (99151–99153). Since moderate sedation is no longer inherent in any procedure beginning January 1, why are these scenarios hitting an edit?
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.
Q: We just heard about a new add-on HCPCS code for 2017, C1842 (retinal prosthesis, includes all internal and external components; add-on to C1841) for the Argus Retinal Prosthesis, but are not sure how to report it along with C1841 (retinal prosthesis, includes all internal and external components). It has nearly the same description as C1841, so this is confusing.
A Comprehensive Error Rate Testing study showed insufficient documentation caused most improper payments for facet joint injections, according to the January 2016 Medicare Quarterly Compliance Newsletter .
Susan E. Garrison, CHCA, CHCAS, CCS-P, CHC, PCS, FCS, CPAR, CPC, CPC-H, reviews when coders should report modifiers -76 and -77 and notes methods for auditing a facility’s accuracy when using these modifiers.
