Common Medical to Dental Procedures and Where to Find Them

With healthcare integrating and consolidating the delivery of healthcare systems, it only makes sense using medical insurance affords better management of care, dental providers are quickly picking up the slack on dental policies and utilizing healthcare coverage, understanding this affords better care for their patients. There are many common dental procedures that ...

CDT and CPT - The Same but Different!

Reporting a CPT code for an evaluation of a patient is based on time and if the patient is a new or established patient. Evaluation and Management codes are different than other codes, it is important to understand how they are used, prior to 2021 they were based on a ...

Final Rule on Communications Technology and 2021 Physicians Fee Schedule

To create a healthcare system that will benefit providers as well as Medicare beneficiaries there have been several new rules issued that begin on or after January 01, 2021. CMS released the final policy and payment provisions on December 01, 2020, which includes the physician fee schedule (PFS) for 2021. ...

Incident To

Just about any large clinic you visit will have non-physician practitioners, or NPPs. These will include physician assistants, nurse practitioners, and clinical nurses for example. Practices and clinics can bill under the NPPs if they are credentialed with the payer, but the reimbursement is only 85% of the fee schedule. There ...

OIG – Fraud and Abuse Study with COVID-19 Testing

According to the Office of Inspector General (OIG), “The coronavirus disease 2019 (COVID-19) pandemic has led to an unprecedented demand for diagnostic laboratory testing to determine whether an individual has the virus. Beyond the COVID-19 tests, laboratories can also perform add-on tests, for example, to confirm or rule out diagnoses ...

My Location and CBSA is Missing!

We often get questions on missing Core Based Statistical Areas, known as CBSAs. CBSAs are used for pricing and other factors according to the geographical location. If you do not see your CBSA, it is important to note they are not missing - it may not have an assignment, according to ...

More COVID-19 Codes Added as of September 8, 2020

The American Medical Association (AMA) recently announced the addition of two more CPT codes in relation to COVID and the Public Health Emergency (PHE). Codes 99702 and 86413 were posted to the AMA website on Tuesday, September 8, 2020 and new guidelines have been added as well.

Not Following the Rules Costs Chiropractor $5 Million

Every healthcare office needs to know and understand the rules that apply to billing services and supplies. What lessons can we learn from the mistakes of others? What if we have made the same mistake?

New Value-Based Payment Models for Primary Care (Primary Care First and Direct Contracting)

This article summarizes the new Medicare value-based payment models: Primary Care First and Direct Contracting.

Podcast - Do you have all the right Dental resources needed to succeed in Dental Medical Billing and Coding?

Discussion between innoviHealth CEO, LaMont Leavitt and Guest speaker, Christine Taxin who is an Adjunct professor at New York University, and President of Dental Medical Billing and Links2Success about making sure you have all the right Dental resources needed to succeed in Dental Medical Billing and Coding. ...

Is COVID-19 Causing Risk Adjustment “Gotcha’s”?

The COVID-19 public health emergency (PHE) has created some possible problems when it comes to risk adjustment. Be sure your organization has implemented policies and procedures to try and overcome these new hurdles.

New and Exciting Changes in the Dental Industry

My colleagues and I are nerds for information on all things billable—or not billable—in the worlds of dental and medical insurance. One of the most puzzling challenges for me over the past 15 years of teaching has been to understand why we on the dental side are segregated out of ...

Coding Injections for Pain Management

Coding for pain management can get confusing. How many injections, the location, and when to use a modifier are all common questions. This article will cover some of the most common injections used in pain management. Trigger Point Injections Trigger point injections are reported by how many muscles are treated using an ...

Coding with PCS When There is No Code

ICD-10-PCS covers ALMOST everything! But not quite! What if a body system does not contain a body part for toes or fingers? What about an elbow? When it does not cover what you are looking for, where do you turn?  To the guidelines, of course! There are ICD-10-PCS guidelines just as ...

OIG Report Highlights Need to Understand Guidelines

A new OIG report once again highlights the necessity for organizations to fully understand requirements for reporting services and having proper documentation. The types of problems addressed in this report are ongoing issues for multiple types of services and specialties and for many different payers.

Office of Inspector General Says Medicare Advantage Organizations are Denying Services Inappropriately

We attended the recent virtual RISE National Conference and had the opportunity to listen to presenters share their knowledge about risk adjustment and HCC reporting and data validation. Among the presenters were representatives from the Office of Inspector General (OIG), who presented findings from encounter data from 2012-2016. They began ...

Use the Correct Diagnosis Codes and Revenue Codes to Get Paid for PAD Rehab

The initial treatment in rehabilitation for patients suffering from Intermittent Claudication (IC) is Supervised Exercise Therapy (SET) for Symptomatic Peripheral Artery Disease (PAD).  Rehabilitation using SET involves the use of intermittent walking exercise, which alternates periods of walking to moderate-to-maximum claudication, with rest.   When reporting 93668 for peripheral arterial disease rehabilitation the following ...

Are NCCI Edits and Modifiers Just for Medicare?

The National Correct Coding Initiative (NCCI) edits were developed by CMS to help promote proper coding and control improper coding that leads to incorrect payments with part B claims. It is important to understand that NCCI edits do not include every possible code combination or every type of un-bundling combination. With that ...

Payment Adjustment Rules for Multiple Procedures and CCI Edits

Surgical and medical services often include work that is required to be done prior to a procedure and post-procedure. When there are multiple procedures done by the same physician, group, or another qualified healthcare professional on the same day, the pre and post work is only required once. Therefore, CMS ...

New ABN Form is Here

The anticipated changes to the Advanced Beneficiary Notice of Non-coverage (ABN) Form (CMS-R-131) have arrived. This important form is issued to the patient or client by providers, physicians, practitioners, and suppliers in situations where Medicare payment is expected to be denied. You can begin using the new ABN immediately if you so wish. However, it becomes mandatory on August 31, 2020.

Understanding UCR Inpatient Fees used on DRGs

HCPCS Codes Were NOT all Created for the Same Purpose

Have you ever wondered why you were unable to find a particular product/code with our DMEPOS search? When looking for HCPCS Level II codes, there are several kinds of codes and not all HCPCS codes were created for the same purpose. If you are searching for a certain HCPCS product ...

Additional COVID-19 Testing Codes Announced

New coronavirus antigen testing codes announced. These are effective immediately.

CMS- Reminder COVID Assessment and Specimen Collection

On March 1, 2020, new codes and rules were released to bill for COVID-19 symptom and exposure assessments, as well as specimen collection. CMS has recently sent out reminders on billing for these services, the proper use of the CS modifier on claims, and how they are handling denials due ...

Should I Bill Dental or Medical?

While you likely find yourself focusing on fewer patients and more on emergency care, it’s a good time to understand how medical billing can allow patients with active infection in the oral cavity to seek the treatment they need.  Forms need to be filled out correctly, and you must carefully follow ...

Medical Necessity using Soap can prevent a future audit!

Medical Necessity using Soap can prevent a future audit! How Do I Correctly Document all my notes on every patient regardless of the insurance I am billing? Medically necessary care is the reasonable and essential diagnostic, preventive, and treatment services (including supplies, appliances, and devices) and follow-up care as determined by qualified ...

Changes in Medicare Advantage and Part D

The Centers for Medicare & Medicaid Services finalized several changes in Medicare Advantage and Part D on Friday.  The Trump administration has finalized several changes in Medicare Advantage (MA) and Part D in anticipation of bid submissions on June 1. The Centers for Medicare & Medicaid Services (CMS) released  Friday that includes ...

Where is the CCI Edit with Modifier 25 on E/M?

If you are not seeing a CCI edit when reporting an E/M code with a certain procedure, it may be that there is no edit. CMS does not have a CCI edit for every CPT code, however, there are still general coding rules that must be followed.  The use of Modifier 25 is one example ...

ICD-10-CM - Supplement information for E-Cigarette/Vaping Reporting

The CDC has released additional information and coding guidance for reporting encounters related to the 2019 health care encounters and deaths related to e-cigarette, or vaping, product use associated lung injury (EVALI).  The update offers coding scenarios for general guidance, poisoning and toxicity, substance abuse and signs and symptoms.  ICD-10-CM Official Coding Guidelines - ...

CMS- Change in Funding for COVID-19 Economic Impact

On Sunday night April 26, 2020, CMS announced they will no longer be "accepting any new applications for the Advance Payment Program, and CMS will be reevaluating all pending and new applications for Accelerated Payments in light of historical direct payments made available through HHS’ Provider Relief Fund." The COVID-19 Pandemic has ...

Clarify the Complexity Please! NDC Codes and Drug Classification Systems

Different Drug classification systems are used to categorize drugs to identify the medication, with each system having their own logic. There are four main drug classification systems used in the United States, not to be confused with a class of drugs or "Drug Class". A drug class is the way drugs ...

Now That is Fraud! Genetic Testing "Public alert"

Genetic testing is becoming very popular. In fact, so popular you might see it in places you would not expect such as a community event, fairs or any event happening in your community. Some labs may even offer FREE screening for genetic testing. Watch for FREE screening announcements or advertisements ...

Dismal OIG Report on Telemedicine

Providers need to understand the rules for reporting telemedicine services. A recent OIG report shows that this is not the case. What problems are being found in documentation claims? As providers are expanding their telehealth offerings, now is the time to understand the potential pitfalls since disallowed amounts will be taken back.

New CPT® Codes Approved for COVID-19 Antibody Identification

On April 10, 2020, the American Medical Association approved and published a revision of code 86318 and added two new codes 86328 and 86769 for reporting Coronavirus [COVID-19] antibody testing.

Medicare Released the Amount they Will pay for COVID Testing Eff 4/14/2020

ADA is Asking for HELP with Third-Party Payers for Dentists

With these unprecedented and extraordinary circumstances, dentists are facing new challenges with reimbursement with what is allowed and covered under their contractual obligations with their payers. The ADA recognizes the struggles dental providers are facing and is urging third-party payers to adopt new reimbursement procedures and adjust their fee schedules to help ...

Financial Impact of CARES Act on Healthcare Providers

The recently enacted Coronavirus Aid, Relief, and Economic Security (CARES) Act has several provisions to ease the financial burden being faced by healthcare providers who have been impacted by the effect of the coronavirus. Learn more about how the Provider Relief Fund and the Accelerated and Advance Payment Program work.

ICD-10-CM Official Coding and Reporting Guidelines Updated for COVID-19

The ICD-10-CM Official Coding and Reporting Guidelines have just been updated to include COVID reporting. Additional information beyond the previously released interim guidelines are included. These are the rules that should be followed for claims submission. The notice states that this is for April 1, 2020 through September 30, 2020.

More Telehealth Changes Announced by CMS

On March 31, 2020, CMS announced further changes to their telehealth program in response to this unprecedented public health emergency (PHE). See this article for further information as well as references & links to CMS information

CMS-Coverage for Therapeutic Shoes for Individuals with Diabetes

Therapeutic shoes and inserts can play a vital role in a diabetic patient's health. Medicare may cover one pair every year and three pairs of custom inserts each calendar year if the patient qualifies and everything is handled correctly.  Medicare Benefit Policy Manual explains what is needed for a person with diabetes to ...

Providing Telehealth Services During COVID-19 Crisis

The rules for providing telehealth services during this pandemic have changed and some requirements have been waived. Please keep in mind that “waiving requirements” does not mean that anything goes. Another important consideration is that Medicare and private payers may likely have different rules so you need to make sure that you know individual payer requirements during this time.

Interprofessional Consult Services

The recent coronavirus crisis has brought non-face-to-face services to the forefront of coding and billing conversations. With the entire healthcare industry focused on caring for patients during an unprecedented and fast-moving pandemic, the goal of increasing patient access while reducing the risk of spreading infection has become paramount. In this climate, ...

2020 Medicare Part D Coverage Gap (AKA donut hole)

Not every Medicare drug plan has complete coverage for prescription drugs - most have some sort of coverage gap, known as the “Donut Hole”. The coverage gap is a temporary limit on coverage under the drug plan. This coverage gap will not affect everyone and begins after you have used ...

Medicare Part D Coverage Gap (Donut Hole) Closes in 2020

Overview of the Part D coverage gap, how it got closed, what the picture looks like for 2020, and long-term outlook.

LATEST COVID-19 INFORMATION FOR BILLING NON-FACE-TO-FACE SERVICES

Healthcare providers and the population at large are concerned about safe access to care considering the COVID-19 pandemic. As a result, we have received many inquiries this week about how to bill for “telehealth” services. Let’s first address that true telehealth services have some pretty stringent requirements from CMS, including that ...

Understand the New Codes for Testing & Reporting the COVID-19 Coronavirus (SARS-CoV-2)

The current coronavirus pandemic refers to COVID-19, a novel or new type of coronavirus known as severe acute respiratory syndrome coronavirus-2 (SARS-CoV-2). The first victim of the virus was identified in Wuhan, Hubei, China at the end of 2019. There is no immunization available to prevent it from spreading and ...

Implementing Telehealth Visits

The following is a step-by-step guide on how to convert office-based encounters to telehealth encounters during the current COVID-19 pandemic. These rules may change post-pandemic, as many changes relaxing existing rules were made on a temporary basis by CMS and commercial payers to facilitate patient access and minimize risk of infection. Step ...

Additional Coronavirus Testing Code Announced

On March 13, 2020, a new CPT code was announced by the American Medical Association (AMA) who maintains the CPT code set. This early release of a CPT code is rare and is effective immediately.

Who Qualifies for Chronic Care Management Services

Per MLN Chronic Care Management Services, the following patients are eligible: "Patients with multiple (two or more) chronic conditions expected to last at least 12 months or until the death of the patient, and that place the patient at significant risk of death, acute exacerbation/decompensation, or functional decline, are eligible for CCM services." Examples of chronic conditions ...

The difference between Jones and Proximal Diaphyseal Fractures of the Fifth Metatarsal (2018-10-23)

Distinguishing the difference between Jones and Proximal Diaphyseal Fractures of the Fifth Metatarsal can be complicated, here are some examples from PubMed;  A Jones fracture currently is defined as an acute fracture of the fifth metatarsal at the junction between the proximal diaphysis and metaphysis of the fifth metatarsal without distal extension beyond the fourth to fifth intermetatarsal articulation. Tuberosity avulsion fracture (also known as pseudo-Jones fracture or dancer's fracture) A proximal diaphyseal fifth ...

Coronavirus - What in the World is it and How is it Coded? 2020-02-20

On December 31, 2019, we learned of a deadly outbreak of an unknown virus, with an unknown cause. We have since learned the virus was identified in Wuhan, China as a novel coronavirus (2019-n-CoV). Until we have more information on the 2019-nCoV, persons with an underlying medical condition are considered high ...

Documentation Skills that Increase Your Coding

Evidence-based medicine such as the updated periodontal staging and caries lesions also gives well-defined information about the clinical condition itself. You cannot just look at the codes, you need to check the policy. When I am coding or teaching coding, you need to use clinical indications when working with documentation ...

Documenting telephone calls at your dental practice is just as important as documenting patient visits.

Documenting telephone calls at your dental practice is just as important as documenting patient visits. Similar to other documentation, the common rule when it comes to call documentation is that if it is not documented, it did not happen. Therefore, every clinically relevant telephone call should be documented. Clinically relevant calls ...

Medicare Announces Coverage of Acupuncture Services

On January 21, 2020, a CMS Newsroom press-release read, This new announcement is both exciting and refreshing. Acupuncture, a key component of traditional Chinese medicine and most commonly used to treat pain, is now being officially recognized by Medicare and several other large payers as a covered, alternative treatment option for ...

Inadequate Exclusion Screenings Could Put Your Practice at Risk

Exclusion screenings require far more than just checking a name on a federal database at the time you are hiring someone. Far too many providers don’t realize that in order to meet compliance requirements, there is MUCH more involved. There are actually over 40 exclusion screening databases/lists that need to be checked.

Q/A: How do we Bill Massage Services?

Question: We are adding a massage therapist soon and have some questions about billing their services.

Billing for Telemedicine in Chiropractic

Many large private payers recognize the potential cost savings and improved health outcomes that telemedicine can help achieve, therefore they are often willing to cover it. While there are several considerations, there could be certain circumstances where telemedicine might apply to chiropractic care.

Non-Surgical Periodontal Treatment

AAP treatment guidelines stress that periodontal health should be achieved in the least invasive and most cost-effective manner. This is often accomplished through non-surgical periodontal treatment.Non-surgical periodontal treatment does have its limitations. When it does not achieve periodontal health, surgery may be indicated to restore periodontal health.SCALING AND ROOT PLANINGScaling ...

Who Knew? There are Three Types of Add-On Codes

Using add-on codes with HCPCS/CPT is not as simple as 123! Although there are three different groups of add-on codes assigned by CMS, these are used to identify code edits. It is easy to see the add-on code with some codes; we can see the instructional notes and phrases such ...

Denials due to MUE Usage - This May be Why!

CMS assigns Medically Unlikely Edits (MUE's) for HCPCS/CPT codes, although not every code has an MUE. MUE edits are used to limit tests and treatments provided to a Medicare patient for a single date of service or for a single line item on a claim form. It is important to understand MUE's are ...

CMS Report on QPP Shows Increasing Involvement

MIPS 2018 participation increased according to the final report issued by CMS on January 6, 2020.

CPT 2020 Changes to Psychiatry Services

As of January 1, 2020, CPT made changes to the health and behavior assessment and intervention codes (96150-96155) and therapeutic interventions that focus on cognitive function (97127). If you code and audit services in this category, you must pay close attention to the changes as they include the removal and ...

Medicare Changes Bilateral Reporting Rules for Certain Supplies

DME suppliers must bill bilateral supplies with modifiers RT and LT on separate claim lines or they are being rejected.

Time Is Up! Jan 1 2020 Claims Will be Denied Without MBIs

New Medicare Card Transition Ends Next Week: Claim Reject Codes Beginning January 1 If you want to get paid you should be reporting MBIs on all of your Medicare claims. The deadline is here: if you are not using Medicare Beneficiary Identifiers (MBIs) on claims (with a few exceptions) after January 1, ...

What to look for when auditing moderate sedation codes 99151-99153

What to look for when auditing moderate sedation codes 99151-99153 Physicians performing diagnostic and therapeutic procedures can now separately bill for the provision of moderate sedation services, but there are some interesting wrinkles to be looking for when auditing these services. Starting in 2017, moderate sedation codes 99151-99157 were created to address ...

CMS- Patient Driven Payment Model Effective October 01, 2019

According to CMS, In July 2018, CMS finalized a new case-mix classification model, the Patient-Driven Payment Model (PDPM), that, effective beginning October 1, 2019, will be used under the Skilled Nursing Facility (SNF) Prospective Payment System (PPS) for classifying SNF patients in a covered Part A stay. Using the new Patient-Driven ...

Reporting the Health Effects of Vaping Now and in April 2020

To report vaping related conditions/disorders, use the official CDC guidelines to ensure proper documentation of vaping related health conditions. There is also a new code that will become effective April 1, 2020.

What did I do today?

What did I do today?   Whether you are auditing inpatient or outpatient documentation, chances are you have come across a situation where the encounters repeat the same story, sometimes day to day, sometimes on every 3-month visit. When EHRs were implemented en masse, a key selling point of almost all of ...

Coding Auto Accident Injuries

There are several different ICD-10-CM code sections that can be used when coding for auto accident injuries. Injury diagnosis codes in ICD-10-CM are found with leading alpha characters S and T. S codes are injuries related to a single body region. T codes are injuries to multiple or unspecified body regions, poisoning, ...

Look What is New for 2020!

Wait a minute... we are not waiting for 2020, this is too exciting! Same great tools and features, this is just a new look for us! We think you will love it! To start using the new view, simply login to your account and go to My Account. At the bottom of your ...

Regence: Dental Procedures Under The BlueCard Program?

This information can be found on Regence/Blue Cross Dental procedures explaining additional benefits for dental procedures. Regence currently does not offer dental benefits, however, there are times a patient can receive treatment with a Blue Cross provider and qualify under their medical benefits. In addition, Regence informs the providers to file these claims ...

CMS says Codes are on the Move!

Have you noticed your LCDs are missing something? CMS is moving codes out of LCDs and into Billing and Coding Articles. MACs began moving ICD-10-CM, CPT/HCPCS, Bill Type, and Revenue codes in January 2019, and will continue through January 2020. Therefore, if there is an LCD with its codes removed, you will find ...

Q/A: Can I Order a TENS unit for a Medicare Patient?

Question Can a chiropractor order a TENS unit for a Medicare patient? We cannot order X-rays for a Medicare patient so I assume we cannot order a TENS unit either. Answer It’s not that you can’t order the TENS unit, it’s just that when it comes to doctors of chiropractic, Medicare only covers ...

Answering the Question: Does my Insurance Cover Chiropractic Care?

The question "Does my insurance cover chiropractic care" is the ongoing question chiropractic offices have struggled with for years. Unfortunately, when it comes to insurance, coverage often varies between payers — even varying between plans for a single payer so there isn't one easy answer.

New Medicare Home Health Care Payment Grouper — Are You Ready?

In 2020, Medicare will begin using a new Patient-Driven Groupings Model (PDGM) for calculating Medicare payment for home health care services. This is probably the biggest change to affect home health care since 2000.

Documentation Tips

Documenting Medical NecessityTo receive reimbursement from medical insurers, you need to make a case that proves that dental surgery is necessary for the patient. To make your case, you need to explain your decision process in terms that a medical insurer can understand, using ICD-10 codes and CPT codes. These ...

And Then There Were Fees...

Find-A-Code offers fees and pricing for just about everything, this article will address two of some of the most common payment systems with CMS. (OPPS) -Outpatient Medicare Outpatient Prospective Payment System. (MPFS)- Medicare Physician Fee Schedule The Fees section on each code page is determined on the type of services...

Are you providing TMD treatment and having a hard time receiving payment from Medical? Take a look at the law for your state!

  TM TREATMENT AND THIRD PARTY INSURANCE COVERAGEMinnesota, in 1987, became the first state to adopt legislation requiring health insurance policies issued within the state to include coverage for the diagnosis and treatment of temporomandibular (TMD) joint disorders and craniomandibular (CMD) disorders on the same basis as other joint disorders. At ...

VA- Reasonable Charges Rules, Notices, & Federal Register

Medically Unlikely Edits (MUEs): Unlikely, But Not Always Impossible

Medically Unlikely Edits (MUEs) were created by the Centers for Medicare & Medicaid Services (CMS) to help lower the error rate for paid Part B claims. MUEs are the maximum units of a HCPCS or CPT code that a provider would bill under most circumstances for the same patient on ...

Why is HIPAA So Important?

Why is HIPAA So Important? Some may think that what they do to protect patient information may be a bit extreme. Others in specialty medical fields and research understand its importance a little more. Most of that importance lies in the information being protected. Every patient has a unique set of ...

Hypertension & ICD-10

Hypertensive Diseases and ICD-10. Helps and examples for these codes.

2020 Official ICD-10-CM Coding Guideline Changes Are Here!

It’s that time of year for offices to get ready for the ICD-10-CM code revisions. As part of that process, it’s also good to know what is going on with the ICD-10-CM Official Guidelines for Coding and Reporting. In the examples listed below, strikeout text is deleted and highlighted text ...

The New ICD-10-CM Code Updates Are Here — Are You Ready?

Chapter 1: Certain Infectious and Parasitic Diseases (A00-B99) A small revision in the description changed[STEC] to (STEC) for B96.21, B96.22, B96.23. Remember, in the instructional guidelines, ( ) parentheses enclose supplementary words not included in the description (or not) and [ ] brackets enclose synonyms, alternative wording, or explanatory phrases. Chapter 2: ...

New Codes for Dry Needling

Find out what you need to know about the new codes for dry needling, also known as trigger point acupuncture.

Vaccine Administration - When The Right Vaccine Code is Not Enough

Understanding how to apply immunization administration codes properly will support correct reimbursement for vaccinations. Reporting the right vaccine code alone is not enough to guarantee proper billing. The majority of the time, providers can charge for the vaccine/product as well as the administration of the vaccine; always consult your payer ...

Q/A: How Do I Bill a House Call?

Question If a provider makes a house call to/for a patient, is there a way that it is represented on the claim form?  A modifier, or something else? Answer Modifiers are not used to identify that a service was performed in the patient's home. However, other modifier rules must be followed (e.g., modifier GP ...

Wellness In the Dental Practice

This course is the beginning of change. Understanding that patients have additional benefits under their dental plans will provide you with the changes taking place in the world of billing. Objectives PROFESSIONAL GROWTH Professionally your team members will be pushed and stretched as you develop your new system. They will require advanced training ...

E-Health is a Big Deal in 2020

The new 2020 CPT codes are on the way! We are going to see 248 new codes, 71 deletions, and 75 revisions. Health monitoring and e-visits are getting attention; 6 new codes play a vital part in patients taking a part in their care from their own home. New patient-initiated ...

So How Do I Get Paid for This? APC, OPPS, IPPS, DRG?

You know how to find a procedure code and you may even know how to do the procedure, but where does the reimbursement come from?  It seems to be a mystery to many of us, so let's clear up some common confusion and review some of the main reimbursement systems.  One of the ...

Attention Chiropractors!

Find-A-Code has created a TOPIC page specifically for Chiropractors. Check it out! We have simplified your search with Articles, Tips, Webinars, and Tools all in one place for your convenience. Be sure to visit us today. Simply go to Findacode.com then hover over TOPICS at the top of the page, then select Chiropractic. ...

Are You Aware of Medicare Advantage Plans Timely Filing Rules?

The Medicare Fee for Service (FFS) program (Traditional or Original Medicare) has a timely filing requirement; a clean claim for services rendered must be received within one year of the date of service or risk payment denial. As any company who has billed Medicare services can attest, the one-year timely filing ...

Understanding Payment Indicators

Understanding how payment works with Medicare payment indicators and the impact a modifier has on payment is vital to pricing. Even if you are not billing Medicare, most carriers follow Medicare's policies for participating and non-participating rules.  Here is an article from Regence on their policy statement, describing the rules ...

Medical ID Theft

Medical ID Theft "So, do you guys think you can do something with that?" John asked angrily at our first meeting with him in August 2017 as he slammed a stack of medical bills, EOBs and collection letters - three inches high - down in front of my partner and I. ...

Healthcare Common Procedure Coding System (HCPCS)

There are three main code sets and Healthcare Common Procedure Coding System (HCPCS), is the third most common code set used. They are often called Level II codes and are used to report non-physician products supplies and procedures not found in CPT, such as ambulance services, DME, drugs, orthotics, supplies, ...

Will Medicare Change Their Rules Regarding Coverage of Services Provided by a Chiropractor?

Two separate pieces of legislation introduced in the House of Representatives (H.R. 2883 and H.R. 3654) have the potential to change some of Medicare’s policies regarding doctors of chiropractic. Find out what these two bills are all about and how they could affect Medicare policies.

The OIG Work Plan: What Is It and Why Should I Care?

The Department of Health and Human Services (HHS) founded its Office of Inspector General (OIG) in 1976 and tasked it with the responsibility to combat waste, fraud, and abuse within Medicare, Medicaid, and the other HHS programs. With approximately 1,600 employees, HHS OIG is the largest inspector general's office within ...

5 Ways to Minimize HIPAA Liabilities

Last year was historic for HIPAA enforcement. The HHS Office of Civil Rights collected a record $23.5 million in settlements and judgments against providers guilty of HIPAA violations. To avoid becoming part of that unwanted statistic, it’s important to pay extra close attention to five key areas of HIPAA vulnerability. Take ...

Helping Others Understand How to Apply Incident to Guidelines

Over the past few months, I have worked with different organizations that have been misinterpreting the "incident to" guidelines and, in return, have been billing for services rendered by staff that are not qualified to perform the services per AMA and CPT. What I found within the variances is that ...

Don't Let Your QPro Certification(s) Expire! Your Certifications Matter!

Hello QPro Members, Just a friendly reminder!                                                                                        ...

What Medical Necessity Tools Does Find-A-Code Offer?

Find-A-Code is a great resource for individuals working in all aspects of healthcare, from providers and ancillary staff to the attorneys and payers who assess and critique the documentation supporting the services performed. When recently asked what tools Find-A-Code has to help support medical necessity, our response was, "We provide many resources ...

Spotlight: Printing Additional Code Information

Did you know you can print the information from Find-A-Code's code information pages? Click the Printer icon on any code information page. You can check/unckeck the boxes at the top to select what information you want to print: It's that easy!

Spotlight: Anatomy Images

When viewing CPT codes, Find-A-Code offers detailed anatomy images and tables to help with coding. For example 28445 offers a table with information to assist classification of gustilo fractures: Click on the image preview from the code information page to expand the image.

Documentation of E/M services for Neurology (Don't Forget the Cardiology Element)

According to Neurology Clinical Practice and NBIC, the neurologic exam is commonly lacking in documentation due to the extensive requirements needed to capture the appropriate revenue. With the lack of precise documentation, it results in a lower level of E/M than that which is more appropriate, which can cost a physician a lot ...

Medicare Approves Reimbursement for Virtual Communication (G2012)

Medicare has taken a stand to recognize communication technology-based services by approving two newly defined physicians' services that will significantly help providers who deal with phone calls and patient triage. One of these services includes:  Virtual check-in (G2012), which allows the provider to be reimbursed for communicating with the patient via ...

Medicare Now Reimburses for Remote Monitoring Services (G2010)

Medicare's 2019 Final Rule approved HCPCS code G2010 for reimbursement, which allows providers to be paid for remote evaluation of images or recorded video submitted to the provider (also known as "store and forward") to establish whether or not a visit is required. This allows providers to get paid for ...

Now is Your Chance to Speak Up! Tell CMS What You Think!

CMS is asking for your input, we all have ideas on how we would change healthcare documentation requirements and get rid of the burdensome requirements and regulations if it were up to us, so go ahead, speak up! Patients over Paperwork Initiative is being looked at to help significantly cut ...

How to Code Ophthalmologic Services Accurately

Have you ever tried to quickly recall the elements required to support a comprehensive ophthalmologic exam versus an intermediate one? Make coding decisions quickly by creating a cheat sheet containing vital information that allows you to quickly select the right code. According to Article A19881 which was published in 2004 and ...

Auditing Hospitalist Services

Auditing Hospitalist Services The inpatient side of coding and auditing can be enormously complex, with many more moving parts than are typically found in the outpatient setting. In this audit tip, we will discuss a few of the challenges that come with auditing one of the most important players in the ...

Noting "Noncontributory" for Past Medical, Family, Social History - Is It Acceptable?

Is "noncontributory" really an unacceptable word to describe a patient whose family history doesn't have any bearing on the condition being evaluated and treated today?

Q/A: For Physical Therapy Claims, What is the Correct Modifier Order?

Question Page 116 of the 2019 ChiroCode Deskbook shows examples for Medicare modifiers. Is this the specific order for the modifiers to be entered? Our practice management software system is advising the GP or GY should be used as Modifier 1 and not as Mod 2 or Mod 3. Also, it shows the ...

Your New Patient Exam Code Could Determine How Many Visits You Get

The initial exam is where the provider gathers the information to determine the need for all the care that follows. It is billed most often as an office or outpatient evaluation and management (E/M) code from the 4th edition of the AMA’s Current Procedural Terminology book. There are actually five ...

RT and LT Modifier Usage Change (effective 2019-03-01)

According to Noridian Medicare, there are new changes required when reporting the RT and LT modifier(s). In the past, it was appropriate to bill the RT and LT modifier on the same line when it was required for certain HCPCS codes. Noridian released a publication stating claims reported with RT/LT on the same ...

Do You Understand Medicare

Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for ...

An Update on the DHS OIG's Effort to Combat Fraud & Abuse

An Update on the DHS OIG's Effort to Combat Fraud & Abuse Every year, the Department of Health and Human Services (DHS) Office of Inspector General (OIG) is required by law to release a report detailing the amounts deposited and appropriated to the Medicare Trust Fund, and the source of such ...

Q/A: Two Payers Both Paid the Claim. Who Gets the Refund?

Question  We have a personal injury situation where we submitted a claim was sent to the patient's auto policy carrier who refused payment. We then submitted it to her other insurance. Eventually, both companies paid her claims. Her auto paid at full value, and her secondary paid at a reduced rate ...

Prioritize Your Patient's Financial Experience

For many years, the ChiroCode DeskBook has emphasized the need for providers to firmly establish the patient’s financial responsibility through clear communication. We even created a “Patient Financial Responsibility Acknowledgment Form” to help providers with this process. Lately, the lack of pricing transparency has been in the news and even ...

Electrical Stimulation and Electromagnetic Therapy Devices

Electrical Stimulation and Electromagnetic Therapy Devices can be used for pain, muscle atrophy, help spinal cord injuries, treat symptoms caused by other medical conditions and can be used in the treatment of wounds. This Regence BC/BS article lists codes and devices and gives guidance on coding from Medicare Advantage viewpoint.

HIPAA Violation Penalties Revised

On April 30, 2019 The Department of Health and Human Services (HHS) announced that “HHS will apply a different cumulative annual CMP limit for each of the four penalties tiers in the HITECH Act.” Unlike other notices which require a proposed rule with a comment period, this notice will take ...

Q/A: If Orthopedic Tests are Negative, do You List Them in Your Treatment Notes?

Question: If orthopedic tests are negative, do you need to still list them in your treatment notes? Answer: Yes. Any tests which are performed by a healthcare provider, regardless of the result, should be documented in the patient record. This record is the only way that a reviewer or another provider ...

Q/A: I’m Being Audited? Is There a Documentation Template I can use?

Question: Our Medicare contractor is auditing claims with 98942. Do you have any suggestions for a template for documentation to warrant the use of 98942? Answer: When you submit a claim with code 98942 you are stating that you have determined that it was medically necessary to adjust all 5 of ...

Medicare Revises Their Appeals Process

There are policy revisions in the Medicare Claims Processing Manual (MCPM), Chapter 29 taking place June 13, 2019. This will give you a heads up on those changes.

Biofeedback - Is it Medically Necessary?

Biofeedback is used for many reasons, and most commonly used for pain management. Each payer should be consulted with to verify coverage when treating with Biofeedback to verify if the treatment is considered experimental or investigational. The majority of payers will list Biofeedback on an exclusions list. Others such as BC ...

OIG Announces New Review For Medicare Part B Payments for Podiatry and Ancillary Services

Due to prior OIG work identifying inappropriate payments for podiatrists and ancillary services, the OIG announced in Feb 2019 they will begin a new review starting in 2020.  The OIG stated they will review Medicare Part B payments to determine if medical necessity is supported in accordance with Medicare requirements.   Part of the ...

Let's Talk High Risk E/M Services

Have you ever assigned a high-complexity E/M code (e.g., 99205, 99215, 99223, 99233, 99245, etc.) and wondered if it would stand up to further scrutiny? Well, let’s take a closer look at the requirements for reporting high-level E/M services.   Both the American Medical Association and Medicare-published E/M Guidelines agree that a ...

CPT Announces 2021 E/M Changes

In 2018, Medicare announced their plans for revamping the Evaluation and Management coding structure and was met with a rapid response from the medical community, including the AMA and many other organizations. As a result, the Medicare changes implemented in 2019 were mostly documentation-related changes that generally benefited providers but were not ...

Coverage for Hearing Aids and Auditory Implants

For hearing impairment, Medicare is firm in its stance on when it will and will not cover hearing correction. In the PUB 100-02 Medicare Benefit Policy Manual, Chapter 16, Medicare cites the Social Security Act by explaining:  "..."hearing aids or examination for the purpose of prescribing, fitting, or changing hearing aids" ...

What is Medical Necessity and How Does Documentation Support It?

We recently fielded the question, “What is medical necessity and how do I know if it's been met?" The AMA defines medical necessity as: It is important to understand that while the AMA provides general guidance on what they consider medically necessary services, these particular coding guidelines are generic and may be ...

Auditing Chiropractic Services

Chiropractic is unique from other types of health care and auditors need to be aware of the nuances of this field. Chiropractic has become the focus of more and more audits as doctors seem to struggle to create records that properly support the care provided to the patient throughout the entire episode.

Q/A: What’s Wrong with the Diagnoses on my Claim?

Question: I got a denial on my claim and it said the problem was with the diagnoses codes that I used. I used M54.15 and M79.2. I don’t understand why this is a problem.

Auditing Ophthalmology and Optometry Exams

Auditing Ophthalmology and Optometry Exams If you work in an ophthalmology group or audit ophthalmology then you are most likely aware of the caveats that exist in this specialty. Ophthalmology and Optometry practitioners can select from either the E/M code set or the Ophthalmologic exam code set. Having this knowledge in ...

Watch out for People-Related ‘Gotchas’

In Chapter 3 — Compliance of the ChiroCode DeskBook, we warn about the dangers of disgruntled people (pages 172-173). Even if we think that we are a wonderful healthcare provider and office, there are those individuals who can and will create problems. As frustrating as it may be, there are ...

Q/A: What do I do When a Medicare Patient Refuses to Sign an ABN?

Question: What do I do when a Medicare patient refuses to sign an ABN? Answer: That depends on whether the patient is still demanding to have/receive the service/supply. If they aren’t demanding the service, then there is no need to force the issue. Just make sure that you still have an ...

Prepayment Review Battle Plan

Any type of payer review can create some headaches for providers and cause problems for a healthcare office. Even for a practice that has taken administrative steps to try and prevent a prepayment review, it can still happen. A prepayment review means that you must include documentation WITH your claim. ...

Looking Ahead - Changes in Dentistry!

In the next 10 years, what is the biggest change dentistry will experience? FW: We all know healthcare in the U.S. is changing rapidly. Dentistry is no exception. My opinion is that several big changes are forthcoming. Most often, I think about changes that benefit patients and/or providers. Here are three ...

Spinal Cord Stimulator Used for Chronic Pain

Chronic pain is a condition that can be diagnosed on its own or diagnosed as a part of another condition. When coding chronic pain, there is no time frame defining when pain becomes chronic pain; the provider’s documentation should be used to guide the use of these codes. ICD-10-CM Diagnosis Codes ...

Corrections and Updates

One constant in our industry is change. Policies change, contracts change, and there are updates. Also, people aren’t perfect and mistakes can be made. So this article will cover a variety of topics. Published Articles We appreciate feedback from our valued customers. We have received feedback regarding two of our articles which ...

Q/A: Can I Tell a Medicare Patient Which Option to Check on the ABN?

Question My patient seemed confused about which of the options they should check. Can I just tell them which one they should check? Answer No! That could be construed as coercion. The official instructions state “Under no circumstances can the notifier decide for the beneficiary which of the 3 checkboxes to select.” Now, this ...

Prolonged Services

Prolonged Services I find in my own audit reviews that the prolonged service code set is often mistreated: they are avoided and not used even when the scenario supports them, or they get overused and improperly documented. Prolonged services are used in conjunction with all types of Evaluation and Management (E/M) ...

Pain Codes in ICD-10-CM

When coding with ICD-10-CM, pain codes can be found in different sections: The Body System affected or site-specific pain codes, such as Low Back Pain M54.5, can be found in Chapter 13. Diseases of the Musculoskeletal system (M00-M99). Other examples might be ocular pain H57.1, found in Chapter 7. Diseases of ...

Clearing Up Some Medicare Participation Misunderstandings

Even though we may think we truly understand what it means to be a participating provider, Medicare doesn’t quite work the way that other insurance plans do. Far too many providers do not understand the difference and get into hot water. To further complicate matters, the rules are different for ...

Q/A: How do we Know Which Codes a Payer Will Allow?

How do we know which codes a payer will allow? The best way to determine the codes (CPT, ICD-10-CM and HCPCS) allowed by a payer is to review their payer policy. While it is good to know the official guidelines (e.g., ICD-10-CM Official Guidelines for Coding and Reporting, AMA Guidelines, Medicare ...

The Impact of Medical Necessity on High Level E/M Services

I was recently asked the question, "Does 99233 require documentation of a past medical, family, and/or social history (PFSH)?"  The quick answer is, "it depends." Code 99233 has the following minimal component requirement: Subsequent inpatient E/M encounters can meet the code level requirement either by component scoring & medical necessity or time & medical necessity. ...

Type of Bill Code Structure (2018-08-30)

The UB-04 claim form (also known as CMS 1450) is the standard facility and residential claim form used to report health claims. The Type of Bill is reported in Block No. 4 of the UB04 claim form. Type of bill codes are four-digit codes that describe the type of bill a ...

How to Report Imaging (X-Rays) of the Thumb

If you've ever taken piano lessons, you know that the thumb is considered the first finger of the hand. Anatomically, it is also referred to as the first phalanx (finger). However, when you are coding an x-ray of the thumb, images are captured of the thumb, hand, wrist, and all ...

Voluntary Repayments

Should you volunteer to repay money from Medicare or other federal healthcare programs if you believe they were the result of errors on your end? The penalties for not doing so could be severe. Under the Federal False Claims Act, if retained overpayments can be shown to be to false ...

Podiatrist Billing for Physical Therapy

It is not uncommon for a Podiatrist to offer Physical therapy as an ancillary service to help promote healing and convenience for their patients. If this is a part of your practice be sure you are aware of the rules and policies from your local MAC carrier and your payer policies on ...

Answers to Your Auditing & Compliance Questions

National Alliance of Medical Auditing Specialists (NAMAS) hosts a forum where auditing and compliance professionals can get answers to their questions, and exchange information with other professionals across the country. Recently, we've received the following question regarding fracture care that we'd like to share below. Q: I recently noticed CPT 26600, ...

Consent for CT Scan - Women

The ADA has forms in over 26 lanuages available to purchase. You also need specific forms for all of the procedures. Even working with patients who are pregnant needs to have a consent with a specialty and collaboration with medical providers. I am showing you one of the forms...

Detection by Nucleic Acid (DNA or RNA) - Amplified Probe Technique

This question was asked on the following lab codes used for testing during pregnancy. "Can the codes below be billed together?  87491- 59, 87591-59. 87081, 87150." YES- CPT code 87081 is used when a specific pathogen is suspected and is appropriate. YES- (X2) 87150 is used for culture, typing, and identification by nucleic ...

Coding Medicare Initial Preventive Physical Exams (IPPE)

The Medicare Initial Preventive Physical Exam (IPPE), also commonly referred to as the “Welcome to Medicare Physical”, may seem daunting to many, but when broken out to identify the requirements is fairly straightforward. Purpose An IPPE helps the Medicare beneficiary (the patient) get to know their healthcare provider at a time when they ...

Q/A Neonate Coding When Child is Transferred (2019/01/17)

Codapedia  Forum - Questions & Answers Q/A: Neonatologist was at the birth of a very critical child, she billed 99468 and then it was decided to transfer the child to another facility, she also billed 99291 and 99292 x 3. Her time was denied, how should she have billed for the initial ...

Everything You need to Know about Drugs

We have it all! Search our WK Drug Database for drugs and pharmaceuticals. When it comes to support and guidance the WK Drug Database offers a paramount search and is conveniently presented in one place.  Pricing  GPIs  NDCs  Billing Codes  Indications/Diseases Packaging Information Active and Inactive and more... Additionally, learn more about drugs and pharmaceuticals that can be used to detect, treat, or monitor ...

QPro - Medical Certifications

QPro (Qualified Professionals) is a member support system dedicated to enhancing coding and management through certification for healthcare coders and managers. Through increased knowledge of coding principles, changes in coding policies, and the experiences of fellow coders and managers in resolving office challenges, QPro members confidently code for maximum and ...

Home Oxygen Therapy

Home Oxygen Therapy Guidelines

Truncated ICD-10-CM Official Guidelines for Coding and Reporting

Adherence to ICD-10-CM official guideline's are required under HIPAA and adopted for all healthcare settings. We have made it easy to access guidelines and made them available on the code information page, either on the page you are viewing or view more information by selecting the ICD-10-CM Chapter Section/Guidelines and ...

CPT Modifiers 96 & 97 for Habilitative and Rehabilitative Services (2018-01-01)

Effective January 1, 2018, CPT modifiers 96 "habilitative services" and 97 "rehabilitative services" will be in effect. There have been questions on whether modifier 96 will be preferred over HCPCS modifier SZ, which describes the same types of habilitative (but not rehabilitative) services, but payers have not yet indicated which modifier ...

An Important Rule that You're Probably Not Following

The HIPAA Security Rule requires that covered entities (your practice) conduct a Security Risk Assessment (SRA) for your organization, at a minimum of once per year. It is critical that practices perform the Security Risk Assessment for multiple of reasons. Not only is it important to comply with rules and regulations, but also, for what you may consider to be a more motivational reason, to protect your practice (and bank account) from what could become disabling fines and penalties.

What are the Rules for Safeguarding Patient Records?

Secure medical records is a broad topic that should be addressed in detail by all practices. There are multiple items to consider when meeting standards to best safeguard protected health information (PHI).