Family Planning Modifier 
Q: We get denials when we use the 96372 code for the administration of Depo-Provera. Can we just use a 99211 instead?A: You could be getting denials on these because you are not using the family planning modifier, which is required by some payers. The provider manual for one payer states that “CPT procedure code 96372 (therapeutic, prophylactic, or diagnostic injection; subcutaneous or intramuscular) was a new code effective with date of service January 1, 2009. The FP (family planning) modifier is allowed with this code. However, some claims have been denied with a denial code that states ‘Claim includes family planning diagnosis and no family planning procedure.’ Please resubmit with family planning procedure/modifier or correct the diagnosis.” Watch those Level II HCPCS modifiers.

NPP Billing
Q: If a NPP sees a new problem on one Medicare patient and bills under the NPP’s own ID, then continues management on the next visit following the physician’s plan outlined in the previous visit, would the billing be incident-to in the second visit but not the first visit? Is it OK to go back and forth depending on the situation on the same day?
A: Yes. Although the regulatory side would not express it that way, (that it’s OK to go back and forth on the same day), that is what the regulations come down to if you have the requisite oversight in the incident-to version.
For a new problem, use the NPP NPI and direct bill. For an established problem with oversight, use the MD NPI and bill in the physician’s name. Good distinction!
There has been discussion among carriers and regulators that once a NPP is using his own number, they should not have to pay for the incident-to version, but as long as the incident-to policy is in effect, what you describe is allowed.
Coding for Multiple Services
Q: When I bill an E&M visit along with an AWV, I have been getting some patient complaints about the two charges — even though Medicare patients don’t pay anything on the AWV. Complaints worsen when I bill a regular 99395 or 99396 to a commercial insurer in addition to an E&M office visit. I thought this was allowed.

Q: What am I missing here? I’m really getting some upset patients.
A: If you are billing two codes because you are performing two distinct services then you are doing this correctly. But don’t forget to include the patient in the discussion.
It is really most efficient to combine an AWV for a Medicare patient with a scheduled chronic disease follow-up visit. In fact, some Medicare patients seem disturbed when they show up for an AWV and discover that there is no exam component. Patients like to have someone “kick all the tires” every once in a while.
But to avoid any confusion, be sure to state upfront what the nature of the visit is. State that two services are being provided. Tell the patient, “You are here today for the AWV and management/assessment of X.”
You will of course document the history, exam, and decision making associated with the problem and outline the elements addressed for the AWV.
If you communicate this well during the encounter you will have fewer problems later. Some practices design work flows so that office or nursing staff participates in “prepping” the patient for the “what we are doing today” conversation. But in the end, the provider really should confirm or restate the services that will be provided.
This can be more difficult for commercial plans when using the 99381-99397 preventive codes along with an E&M. Not all plans cover both codes on the same day and this will surely get a rise out of patients.
In this case, it is more important to check the patient’s coverage when the visit seems likely to be one in which multiple services will be provided. But again, the key to avoiding the phone calls and upsets is communicating along the way what you are doing.
The trickiest visit of this sort is when it starts as a well visit only, and a finding is made either on examination or as a result of the ROS which then requires significant problem management. In this case, a problem crops up unexpectedly and no one — neither you nor the patient — was expecting two types of codes.
Once more, the best course is likely to communicate with the patient that you need to account for the tests ordered and work done and that there will be a problem-management component to this visit.
A best practice is to post a policy or guide to combination visits somewhere in the office where patients can see it. No surprises is the goal.
Modifiers and Bundled Codes
Q: I recently started working at an orthopedic practice and I am working on denied claims. I have come across several claims that have been billed with CPT codes 29881 and 29877-59. Different payers are denying the claims stating the payment for 29877 is included with the primary code, even though modifier 59 was used. Is this correct?
A: The first place you should refer to is to CCI. You’ll see that 29887 is a Column II component of 29881. The modifier indicator is “0” — which tells you that no modifier will break the edit.
The modifier you would likely have used is 59, but even that won’t work here. Modifier 59 will break bundling edits in some cases, when indicated by the CCI tables, but it isn’t fairy dust!

By: Bill Dacey

-source: http://www.physicianspractice.com/icd-9/family-planning-modifier-npp-billing-coding-multiple-services

With the extended deadline of ICD-10, medical practices now have time till October 1, 2015 to train and test their capabilities with the new coding system. This delay has given another year to the providers to gear up for the new coding standard, but it has also affected the healthcare industry as a whole.
Effect of ICD-10 Delay on Vendors
Many EHR vendors have welcomed this year long delay in ICD-10 compliance deadline. This is because of the increased workload and the pressure to meet the new 2014 criteria for certifying EHR technology. Practices report to not been given adequate time for their developers to ensure ICD-10 readiness for their products. Some vendors were prepared for the original deadline though, but others remained unprepared. Since many practices use small vendor products, another year will surely help everyone come on the same page in 2015.
How has the Delay Affected Providers?
In order to prepare for ICD-10, providers had to deal with costs related to overhauling of IT departments and training coders. They had to overcome various hurdles associated with the implementation of the new coding system. Now that the deadline has been extended, they are faced with additional costs to either maintain the ICD-10 transition process or to stop and restart the process when nearing the deadline in October next year. Since these are operating costs, providers are not likely to be reimbursed for this expenditure.
Readiness of stakeholders, including payers, clearinghouses and vendors has also been one of the largest concerns for providers. The healthcare industry loses a lot of money every time ICD-10 is delayed.
The delay has affected stakeholders who had already spent thousands of dollars and sizeable time preparing for ICD-10. It has affected the health care educators, students of coding and Health Information Management (HIM) programs along with HIM professionals who were prepared for the new system. It has also affected the job prospects for students who learnt to code exclusively for ICD-10.
It is difficult to decide whether the effects are positive or negative, but the delay surely has had its presence felt even before its implementation in the healthcare industry in the US.
 According to American Medical Association, the delay in ICD-10 implementation will give the providers an extension to the timeline when sizeable amount of time and money is being spent by them on multiple government initiatives such as pay-for-performance initiatives or the Meaningful Use program
In order to sail through the reimbursement challenges and ensure readiness for the new coding system, many practices are outsourcing their billing and coding requirements to companies like MedicalBillersandCoders.com. MBC has a team of well-trained, certified coders and billers who are experts at maximizing revenue and strengthening the revenue cycle. By outsourcing their billing needs to MBC, physicians have been able to eliminate costs related to hiring and training coders and on implementation of health information technology.
HIM experts at American Health Information Management Association are of view that ICD-10 delay has affected the healthcare industry because the switch to a more specific and modern coding system has been prolonged too much. According to them, ICD-10 should be implemented by the next year as it will play a vital role in improving healthcare provision and healthcare reporting.

By: Jacob Thomas

– Source: http://www.medicalbillersandcoders.com/blog/what-percentage-of-healthcare-industry-is-affected-due-to-icd-10-delay.html#sthash.ECcavGmA.dpuf

CPT® released three new E/M services in 2011, to be used for the second and subsequent days that a patient is in observation status in the hospital.
The codes are 99224–99226 and they are out of sequence in the CPT® book. They require the same level of documentation as the three subsequent hospital visits.
99224 requires 2 of 3 of a problem focused interval history, problem focused exam and straightforward or low medical decision making. The typical time is 15 minutes and it carries .82 RVUs.
99225 requires 2 of 3 of an expanded problem focused interval history, an expanded problem focused exam and moderate medical decision making. The typical time is 25 minutes and it carries 1.45 RVUs.
99226 requires 2 of 3 of a detailed interval history, a detailed exam and high complexity MDM. The typical time is 35 minutes and it carries 2.17 RVUs.
An interval history means that no past medical, family or social history is required.
CPT® is instructing all clinicians (admitting and other treating physicians) who see a patient in observation status to use these subsequent observation visit codes. However, as of this writing, some CMS contractors are indicating that only the physician who admitted the patient to observation status should use these codes. Physicians other than the admitting physician who see Medicare patients in observation status should bill with office/outpatient codes (99201—99215).

As of Jan. 18, 2011, it looks like we’ll have different CPT® and CMS rules for using these new codes.

Author: Codapedia Editor

- Source: http://www.codapedia.com/article_521_Subsequent-Observation-Services.cfm#sthash.j9XbgW4z.dpuf

I can count on two consistent issues in coding audits. Doctors report that their patients are, in general, sicker than patients in other practices. Coders report that their physicians are, in general, worse documenters than physicians in other practices and select codes that are too high based on the volume of the documentation without considering the medical necessity for the visit. Because medical necessity is hard to define, some compliance policies mandate that medical decision making be used as a substitute for medical necessity. As a frequent arbiter to these discussions and an experienced E/M auditor, I am uniquely positioned to comment on this topic.
The most often quoted reference in the discussion comes from the Medicare Claims Processing Manual, Chapter 12 Section 30.

Medical necessity of a service is the overarching criterion for payment in addition to the individual requirements of a CPT® code. It would not be medically necessary or appropriate to bill a higher level of evaluation and management service when a lower level of service is warranted. The volume of documentation should not be the primary influence upon which a specific level of service is billed.

It is brief and to the point, but provides no mechanism to operationalize the guidance. It relies solely on physician’s or coder’s judgment. For this joint pain, how much of an exam was needed? For that throbbing headache, what systems needed to be reviewed? What part of the volume of the detail was medically necessary for the physician to document and what part of the volume of detail was simply the doctor aiming for a higher level of code? Or just using the tool–the electronic health record—provided? The spirit of the guidance is clear but the interpretation is based on judgment.
The Documentation Guidelines themselves and the audit tools that sprang up after the guidelines were released provide a more objective tool in auditing an E/M note. Using these tools, the level of service is based upon the key components of history, exam and medical decision-making. Some codes require all of the three components and audit to the level of the lowest component. Some services require only two of the three key components. Of course, the CPT® book defines an E/M service as having seven components (history, exam and medical decision making are the three key components; most audit sheets have time as the fourth. Counseling coordination of care, and the nature of the presenting problem are the final three components.) The CPT® book includes charts for all E/M services in which the nature of the presenting problem is listed. It also states that counseling coordination of care at the nature presenting problem are considered “contributory factors in the majority of encounters.”
The CPT® book devotes a section to describing the five types of presenting problems, which are defined as minimal, self-limited or minor, low, moderate or high. Within the Tabular listing of E/M codes, CPT® assigns a type of presenting problem to each level of service. For example, for 99203, usually the presenting problem (s) are of moderate severity. CPT® describes moderate severity (in the E/M Services Guidelines section of the book) as “A problem where the risk of morbidity without treatment is moderate; there is moderate risk of mortality without treatment; uncertain prognosis OR increased probability of prolonged functional impairment.”
The medical necessity for performing the key components of history and exam are determined by the nature of the presenting problem, the patient’s own personal history and the clinical judgment of the provider. The medical decision making, that is the diagnostics ordered, the assessment and the plan are formulated as a resultof the nature of the presenting problem, the patient’s past medical history, and the history and exam performed at that visit. Medical decision-making is the outcome of the visit and is not a substitute for medical necessity. If CMS had wanted medical decision making to be that substitute then the Medicare Claims Processing Manual would read, “medical decision-making is the overarching criterion in selecting an E/M service” instead of medical necessity. If CMS had wanted medical decision making to be a substitute for medical necessity than either medical decision-making would be required in determining the code or all codes would require all three components.
Physicians do need to use their electronic health records in a way that more clearly documents what happened at the visit. In most cases that means document what would have been dictated, and be prudent in copying and clicking. Length of note doesn’t win a prize. Coders need to recognize the difference between the medical necessity of performing a history and exam based upon the nature of the presenting problem and the patient’s condition and medical decision making that is the clinical outcome of the encounter. Organizations should seriously consider how policies and incentives are effecting coding for E/M services.

Author: Codapedia Editor

- Source: http://www.codapedia.com/article_559_Medical-Necessity-is-not-Medical-Decision-Making.cfm#sthash.PdPzONGd.dpuf

Whenever a Medicare Administrative Contractor (MAC) releases a list of the top reasons for claims denials, the list almost never fails to include duplicate claims.

When the MAC perceives the claim to be a duplicate, based typically on a match of the patient identifying information, furnishing provider, date of service and billed codes, processing of the service is going to be stopped cold. You’ll see CO18 on the remittance advice, which is the code for a duplicate claim.

Providers typically don’t intend to re-bill the same service, but the MACs and CMS alike have expressed their frustration with the clogging of the processing system with duplicates. To put it in perspective, in one quarter alone in 2010, Cahaba received 489,738 duplicate claims in Alabama, Georgia, Mississippi and Tennessee.

Filing a lot of duplicate claims exposes you to some risk, as the MAC can see you as either an abusive biller or unfocused on provider education. At the worst, your practice could leave a perception that it’s trying to game the system.

Here are some causes of duplicate claims and ways to solve them:
• Initial claim not yet processed: If a claim is suspended for medical review or delayed in processing, it’s possible you’re submitting a claim that is still being processed. Or your software may be set up to automatically refile claims that haven’t yet been paid by all payers. If you know you’ve already filed a claim, check to see if it’s been adjudicated and posted either as a payment or a denial before simply re-filing. When it hasn’t been paid, address the reasons it hasn’t been paid before trying to resubmit. Set your software not to automatically refile Medicare claims.
• Only submit corrected claim lines: When you get a partial payment on a claim with multiple lines and you want to correct and resubmit the line(s) that were not paid, submit only those lines. Never resubmit a claim line for which you’ve already received a payment.
• Don’t split claims for resubmission: When you get back a claim with multiple lines that was denied entirely, don’t try to split it into two claims and send it back to the MAC. It’s only going to get denied again and raise the same red flags with the MAC.
• Only one E/M service per physician or physicians of the same specialty within a group practice per day: You can’t bill more than one E/M service for the same date of service for the same physician, or physicians of the same specialty within a group. Combine all of the work into one E/M service for that day. The only exception is for unrelated problems, but if the problems are unrelated the claims won’t be duplicates.
• Claims resubmitted when no payment is made: A claim may be adjudicated in your favor, but because the patient hasn’t met his or her deductible yet, no payment is posted. Those balances are collected from the patient, not from Medicare. Because Medicare applies the deductible at the adjudication stage, you can’t sit on an already processed claim in the hope that the patient addresses the deductible with services rendered by other providers.
• Make sure a claim is not pending based on additional information needed: Medicare denies a claim when the claim is able to be processed, but based on the information provided the MAC does not believe it is a payable claim. When data are missing or incorrect, such as the patient’s name or address, the claim will be rejected until the payer gets that information. Check the status of these claims via the remittance advice or the MAC’s interactive voice response system before just re-filing it.

Author: Scott Kraft

- Source: //www.codapedia.com/article_646_6-ways-to-stop-filing-duplicate-Medicare-claims.cfm#sthash.8p3dffIv.dpuf

We’re all very much aware — some might feel painfully aware — that payer models are transitioning us away from fee-for-service to a new era in which reimbursement is based on outcomes and provided value. As a result of that transition, effective revenue cycle management (RCM) in the near future will bear little resemblance to traditional billing practices.

That’s because traditional billing is rooted in the fee-for-service model in which information, originally paper-based, advanced directly from the point of care to the back office. Doctors saw patients and made records of procedures. Those records went to the back office for coding and the preparation of bills for services rendered. Billing volume corresponded to clinical transaction volume.

While simple, that method of revenue cycle management had plenty of challenges, most of them resulting when patient information collection and clinical care separated from billing and from the manual processes that linked them — error-inducing workflow that contributed to claim delays and denials. Even as practices moved toward the electronification of patient data by adopting electronic health record systems, there was typically no automated flow of information between a practice’s EHR and RCM systems to address these issues.

That situation began a course correction recently with a new generation of integrated EHR/RCM solutions that deliver more accurate information to the payer for faster, cleaner claims and fewer denials. As consumers take on a larger share of payment responsibilities, EHR/RCM integration has also made it possible to minimize “sticker shock” and improve patient satisfaction by identifying patient financial responsibilities at check-in.

Those advantages in leveraging data flow are just the start, and the move toward clinically driven RCM — in which data captured electronically at the point of clinical decision-making drives revenue cycle management — will provide a solid foundation to accommodate the new payer reimbursement models. Before that can happen, practices will need to move beyond older RCM approaches that merely document services and then assign fees to those services.

Identifying and closing care gaps, managing a patient population within a shared-risk program and contributing to improved care delivery within a region are major initiatives that shift the emphasis from clinical transactions toward population health. Participating in revenue streams associated with that shift will require a broad emphasis on clinically driven RCM. For example, systems will need to identify diabetics who haven’t been in for a foot exam as well as those who have. Practices must also engage patients with monitoring and reminders outside of office visits, and translate that activity into the revenue cycle by effectively managing consumer populations as never before.

The reason is simple: Future revenue streams will reward physicians in part for healthy patients who do not have to come in for frequent treatment along with those who do, as financial performance becomes increasingly tied to the health of the population of healthcare consumers the provider serves.

While it remains to be seen precisely which of the new payer models will eventually dominate in the move away from fee-for-service billing, all emerging models point the way toward rendering traditional billing approaches ineffective. Practices at the forefront of clinically driven RCM today are not only reaping benefits in immediate improvements to billing and patient satisfaction; they are also among those that are best prepared for the new era in value-based reimbursements.

By : Tee Green – CEO of Greenway Health

Following four years of steady increases, heart doctors’ compensation dropped by nearly 8 percent.
That’s according to MedAxiom’s 2014 Provider Compensation & Productivity Report, which also found that cardiologists’ productivity dipped by nearly 5 percent.
The pace of transition from private practice into integrated models — either through hospital employment or professional services agreements — slowed down in 2013, which partially explains the compensation pullback, according to MedAxiom.
[See also: Women doctors on the forefront of care, innovation.]
Physicians in an integrated setting, in fact, continue to out-earn their private peers by more than 30 percent. Indeed, those independent doctors saw overall compensation drop almost 9 percent.
Contrary to the earning figures, however, private physicians in 2013 out-produced their integrated peers by almost 6 percent.
Geography continues to play a role in compensation as well. Physicians in the Midwest hold the top compensation spot ($559,004 median) with those in the Northeast at the bottom ($460,815 median).
Changes to the business
It’s not bad news for everyone. Interventional cardiologists, for instance, still ruled the day, pulling in a median of $558,824.
The cardiology mix of business continues to change as well, but unlike in years past where the trends were all downward, physicians achieved varied results in 2013.
New patients per cardiologist, for instance, increased slightly as did the total number of cognitive encounters. The ratio of work performed in the hospital versus the outpatient setting inched back up for a second straight year — somewhat contradicting conventional wisdom on the migration of inpatient to outpatient nationally.
For other key volumes like catheterizations and Percutaneous Cardiac Interventions, the survey found that declines have hit bottom and are beginning to stabilize, while non-invasive imaging saw further erosion.
MedAxiom’s research is based on data submitted by 134 cardiology programs representing 2,554 cardiologists across the country. Of those responding groups, 97 are integrated and 37 remain private practices.

Author : Frank Irving

Selective renal angiography (left lower renal artery) (Photo credit: Wikipedia)

Coding Selective catheterization of both renal arteries in medical coding
Renal arteries arise directly from the aorta. Renal arteries form a separate vascular family. Vascular families are coded always separately. When we code catheter placement code for renal arteries, we have separate CPT® codes. Selective catheterization of both renal arteries have a single CPT® code. This CPT® code includes everything from taking access to placing the catheter in the renal artery. These are actually new codes used mainly for renal artery catheterization.

CPT® codes for selective catheterization of both renal arteries
The CPT® codes used for coding renal arteries are 36251, 36252, 36253 and 36254. These CPT® codes include all the minor procedure required for catheter placement. The CPT® codes are allocated on the basis of branches of renal artery. So, the main renal artery and it branches have specific CPT® code. The main renal artery is stated as First order renal artery and its branches as second order. We don’t have the third order or any other code for higher order arteries. The main renal artery is given selective catheter placement code and it branches are given superselective catheter placement codes. The arteries of second order or of higher level will be coded second order CPT® Code. The CPT® codes used for first order renal arteries are 36251 and 36252. The CPT® codes used for second order or higher level of renal arteries are 36253 and 36254.
Procedures include in Selective catheterization of both renal arteries
The abdominal aortogram CPT® Code 75625 is included in selective catheterization of renal arteries. The code description states that it includes flush aortogram or abdominal aortogram. Also, the Fluoroscopic or ultrasound guidance codes are included in these CPT® codes. Supervision and interpretation codes are also include in these procedures. So, never code following codes with codes from 36251-36254.
75625- Abdominal aortogram
76937- Ultrasound guidance
77001-Fluoroscopic guidance
Also, conscious sedation is included in these CPT® codes. So, we do not codes conscious sedation separately with CPT® codes from 36251-36254.

Unilateral and bilateral selective catheterization of both renal arteries
The study which includes only selective catheterization of one side of main renal artery is code as 36251. Since, we have renal arteries on both the sides the CPT® codes are divided as unilateral and bilateral. Same, when the study of both sides of main renal arteries is done, the code used is 36252. Never, use a 50 modifier when we are coding these CPT® codes. This modifier denotes bilateral procedure. We have separate code for bilateral procedure so we can avoid using 50 modifier.
Coding for selective catheterization of both renal arteries branches
The renal arteries branches have separate code, 36253 and 36254. These branches come under second order catheterization codes. These codes are similar to CPT® codes for main renal arteries. These codes are used for any higher order or level of arteries. We cannot use first order codes with second order CPT® codes. The second order CPT® codes include the first order code. This is one of the rules for coding vascular families. Second order catheter placement is also stated as superselective catheter placement. They also have separate codes for unilateral and bilateral renal arteries. For unilateral second order renal artery catheter placement we use 36253 CPT® code. For bilateral second order renal artery we use 36254 CPT® code. Also, these procedures include all the minor procedures which are included with the first order CPT® codes.
Hope, now you can easily code catheter placement codes for renal arteries. Please share if you liked the article.

Author: jitendra az

- Source : http://www.codapedia.com/article_731_Selective-catheterization-of-both-renal-arteries.cfm#sthash.sAMD9QFJ.dpuf

Call me crazy, but it is always exciting to me when I assist a practice in getting reimbursed on unpaid or delinquent claims. Claims that were denied, viewed as uncollectable, past filing deadline, or a multitude of other reasons. I even have a little dance that I do! Why not? We need to get excited about our jobs, and in these times of decreasing health care reimbursement, it is crucial that we push forward and adopt a motto of “NO CLAIM LEFT BEHIND”! Here are a few tips to help you become persistent in your reimbursement efforts for your practice.
First and foremost, don’t get behind. I know it seems elementary, but it is very important to have solid Billing Processes. Set goals and tasks that need to be met daily, weekly, and monthly, and mark them on your calendar to ensure you comply.
Resolve payment denials and other claim related requests as they come in. Don’t let them stack up.
Communicate denial trends with your provider or other appropriate staff. There may be coding, office policy, or even staff issues that need to be addressed. Resolving the issue quickly can help avoid future denials and possible compliance risks.
Identify your delinquent claims on your Aging Report monthly. Most Practice Management Systems can easily compile this report. Go through each claim to follow up to see why the claims has not been paid.
Record detailed account notes on what you have done on each claim. Include dates, contact names, and other pertinent details. This proves vital when you need to access the account again and take further action on a claim.
Know and understand all of your top Payer guidelines for appeals, reconsiderations, and resubmission of corrected claims.
Develop a QRG (quick reference guide) for all of your payers that includes required information when working your claims.
Finally, take action on every one your delinquent claims and follow through to resolution. In most cases, persistence will lead to positive results.

Author: shannon bosley

– Source: http://www.codapedia.com/article_552_No-Claim-Left-Behind.cfm#sthash.CY2tZxXr.dpuf

Accounts Receivable benchmarks are measures of how successfully and how quickly the practice collects their revenue for services provided.
These measures include the gross collection ratio, the net collection ratio, aging report and day in receivable outstanding.
Physician practices should make a special effort to collect revenue and cash from patients with past due balances who are being seen in the practice, patients who have a budget plan and patients who have high deductible plans or no insurance. The longer the time between the date the service and the collection effort, the lower the chance of collecting at all.
Measure each of the AR benchmark data monthly and track your results on a monthly and year to date basis. Use external data to compare your specialty to other specialists. The key data are at least: gross collection rate, the net or adjusted collection ratio, an aging report, or an aged trial balance and the total days in accounts receivable outstanding.

Author: Sally

- Source: http://www.codapedia.com/article_81_Accounts-Receivable-Benchmark-Data.cfm#sthash.H8aHLa0W.dpuf