Optimize Revenue with Improved Claims Denials Management

No matter how diligent your billing staff is about billing charges out correctly, it is inevitable that you will receive claim denials from payers, whether they are justified or not. A claim denial means that no payment is being received for the service, and unless you have someone (or technology) analyze the denial to determine if the denial is appropriate or not, you will not receive payment for the service(s) rendered . Denials come in …

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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 …

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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, …

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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 …

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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 …

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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 …

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Big Changes in Medicare Evaluation and Management Reimbursement

The Centers for Medicare and Medicaid Services (CMS) has published the proposed changes for the Calendar Year (CY) 2019 Physician Fee Schedule (PFS).1 Probably the most controversial of these proposed changes is the Patients Over Paperwork initiative, which streamlines documentation requirements and reimbursement for Evaluation and Management (E/M) services in the office and outpatient setting, affecting Current Procedural Terminology (CPT) codes 99201 through 99215. CMS has announced that it plans to eliminate differential payments for …

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Small Errors Could Cost Big Bucks When Billing for I&D

Q: While reviewing charts where incision and drainage (I&D) procedures were being performed, I came across instances where Current Procedural Terminology (CPT) code 10060, “Incision and drainage of abscess (eg, carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia); simple or single” was billed for treatment of an abscess on the finger. I believe this is an error, since this procedure involved an abscess of the finger pad and not just paronychia. Can …

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2019 International Classification of Diseases, 10th Revision, Clinical Modification (ICD-10-CM) Codes

October 1, 2018 will bring 279 new codes to ICD-10-CM. Combined with 51 deactivated codes (and 143 revised codes), that brings the total number of ICD-10-CM codes to 71,932. We identified a few examples that are especially important for urgent care coders to be aware of; a complete list of ICD-10-CM changes can be found on the CMS website at https://www.cms.gov/Medicare/Coding/ICD10/2019-ICD-10-CM.html.   Chapter 2: Neoplasms (C00-D49) Melanoma and other malignant neoplasms of the skin The …

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Clarifying the Coding for Splint and Cast Application by Nonphysicians

Q: I would like clarification on an article I read in The Journal of Urgent Care Medicine (JUCM) online archive. The article, Splint and Cast Application Performed by Someone Other than Physician, referenced that nonphysician staff could bill for splint and cast application. Will you please expand on the references and confirm that we can bill for splint and cast application if it is done by someone on staff other than the physician? A: Yes, …

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