Get Ready for the Next Round of Changes to E/M Guidelines

The American Medical Association has announced it is taking the first steps towards revising the new Evaluation and Management (E/M) guidelines that the Centers for Medicare and Medicaid Services (CMS) introduced last year to reduce the administrative burden on clinicians with the Patients over Paperwork initiative.1 Effective as early as January 1, 2021, office visit Level 1 E/M code 99201 will be deleted. Additionally, while the history and exam will be required to be reviewed by the provider, they will not be scored as key components for selecting an E/M …
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Be Aware: The CCI Edits, They Are a Changin’

The Centers for Medicare and Medicaid Services announce an update to claim adjudication rules for National Correct Coding Initiative Procedure-to-Procedure edits to allow bypass of an edit if modifiers 59, XE, XS, XP, or SU are appended to either the column one or column two code. In 2015, the Centers for Medicare and Medicaid Services (CMS) introduced the following modifiers, referred to as X{EPSU} and intended to provide more information in scenarios where modifier -59, “Distinct procedural service,” would be appropriate: XE, “Separate encounter, a service that is distinct because …
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Correct Modifiers Make All the Difference When Coding for X-ray Services

Q: During a recent internal audit of claims where x-rays were being billed, it was brought to my attention that we were not using the appropriate modifiers since we use computed radiography (CR) x-ray machines. What are those modifiers and will using them affect my reimbursement? A: As outlined in the Consolidated Appropriation Act of 2016, the Centers for Medicare and Medicaid Services (CMS) imposed reimbursement cuts to the technical component for x-rays performed on older technology beginning in 2017 with increased cuts in 2018 and 2023. (See Table 1.) …
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UnitedHealthcare Discontinuing S9083 and S9088 in Multiple States and Medicare Telehealth Policies

Beginning April 1, 2019 UnitedHealthcare will revise their policies to discontinue reimbursement for HCPCS code S9083, “Global fee urgent care centers” in some states (see Table 1). The change affects UnitedHealthcare commercial plans, United Healthcare Oxford, and UnitedHealthcare Community Plan policies. Additionally, UnitedHealthcare Community Plan will no longer reimburse HCPCS code S9088, “Services provided in an urgent care center.” Providers should report the Evaluation and Management (E/M), and/or procedure code(s) that specifically describes the services provided, consistent with the Current Procedural Terminology (CPT) manual.  Q: Are the 2019 telehealth Healthcare …
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Navigating the Credentialing Process to Maximize Revenue and Minimize Denials

What is the best way to get my practitioners credentialed with various insurance companies and networks? It is frustrating to try and navigate this convoluted process. I am asked by each insurance company to complete a mound of paperwork and collect a stack of supporting documents for each practitioner. Then I wait months for approval notifications and effective dates. As a result, we end up losing some patients because they want to be treated at medical offices where their in-network benefits will apply. If we do treat patients with an …
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