Denial Rates for Modifiers 76, 77 & 91
In a recent release of 2018 benchmarks regarding modifiers 76, 77 and 79, the data of payment vs denials is staggering. For instance, a total of 159 codes reported with 91 and 249 codes that were reported using modifier 77 all had a 100% denial rate. Compared to the 952 codes that were denied when reported with 76 that doesn’t seem so bad. But considering your bottom line and the time it takes your team to resubmit it adds up to money lost. nnHowever when we step back and look at the big picture we see that modifier 76 although the most reported, still had the lowest overall denial rate at just 5%.n
| Modifier | Times Reported | Percentage Denied | Total Denied | Total Paid |
| 76 | 119,200,000 | 5% | 5,960,000 | 113,240,000 |
| 77 | 706,223 | 14% | 98,871 | 607,352 |
| 91 | 3,000,000 | 20% | 600,000 | 2,400,000 |
n nnWatching your reporting trends and utilizing billing reports will help make sure you avoid costly denials. Be aware of National Baselines for your specialty and where you fall within them.
As Risk Adjustment (RA) and Hierarchical Condition Category (HCC) coding continue to grow and become common practice it is important for not just coders, but also our clinicians to recognize its importance and the effect it has on reimbursement. Below is an example of a procedure and notes regarding coding and why our clinician must be queried in order for the claim to be submitted. Do you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. 
During the State of the Union address, President Trump discussed the price transparency rule and slammed Medicare for all. Below are some of the main points President Trump made during the speech which included drug pricing plans, association health plans, and more. Read below for more information!nnPresident Donald Trump delivered his third State of the Union address Tuesday night, elaborating on several of the administration’s major healthcare initiatives.nnUnlike his previous two State of the Union speeches, Trump mainly avoided discussing the Affordable Care Act and instead focused on new policies like the administration’s price transparency rule and efforts to lower prescription drug prices.nnTrump also did not discuss the Health Adult Opportunity initiative, which was announced by the Centers of Medicare & Medicaid Services (CMS) last week.nnHe did criticize proposals to institute a ‘Medicare for All’-style system, which has been embraced by several Democratic presidential candidates.nn”To those watching at home tonight, I want you to know we will never let socialism destroy American healthcare,” Trump said.nnBelow are the healthcare policies discussed during Trump’s speech, including reaction from industry stakeholders to his remarks.nnPotential impact of price transparency rulennTrump heralded the administration’s price transparency rule, which will go into effect in 2021, saying it will save families “massive amounts of money for substantially better care.”nnHe also added that experts believe the rule, which is being challenged in a lawsuit by provider organizations, “will be even bigger than healthcare reform.”nnOn the topic of improved price transparency, Trump said patients should never be “blindsided” by medical bills but did not address the issue of surprise medical billing, which has stalled on Capitol Hill in recent months.nnOffensive against Medicare for AllnnTrump attacked Medicare for All proposals that have been put forward by congressional leaders, warning that such policies will “take away your healthcare, take away your doctor, and abolish private insurance entirely.”nn”132 lawmakers in this room have endorsed legislation to impose a socialist takeover of our healthcare system, wiping out the health insurance plans of 180 million very happy Americans,” Trump said.nnIn addition to his critiques of Medicare for All, Trump assailed California Governor Gavin Newsom’s recent proposal to extend public healthcare coverage to undocumented immigrant seniors.nn”These proposals would raid the Medicare benefits of our seniors and that our seniors depend on while acting as a powerful lure for illegal immigration,” Trump said.nnCalls on Congress for bipartisan drug pricing plannnOn the prescription drug front, Trump highlighted the administration’s challenge to the pharmaceutical industry and pointed to the record number of generic drugs to receive approvals from the Food and Drug Administration last year.nnHe said that last year marked the first time in 51 years that prescription drug prices went down but added that Congress can do more to lower prescription drug prices.nnTrump specifically referenced conversations he has had with Senate Finance Chairman Chuck Grassley, R-Iowa, who recently told Stat News that Trump has not advocated enough for a bipartisan drug pricing bill he coauthored with Ranking Member Sen. Ron Wyden, D-Ore.nn”I am calling for bipartisan legislation that achieves the goal of dramatically lowering prescription drug prices,” Trump said. “Get a bill on my desk, and I will sign it into law immediately.”nnSome Democratic House representatives vocally rebuked Trump’s points on drug pricing, expressing support for the Elijah E. Cummings Lower Drug Costs Now Act, which passed in the chamber in December.nnPraise for association health plansnn
Trump mentioned the administration’s move to introduce association health plans (AHP), saying the options are “60% less expensive, and better” than other available forms of coverage.nn”A good life for American families also requires the most affordable, innovative, and high-quality health system on Earth,” Trump said.nnTrump did not mention the ruling by a federal judge last spring that blocked key provisions of AHPs and the administration’s subsequent decision to file an appeal.nnProtect Medicare and patients with pre-existing conditionsnnDespite not mentioning the ACA, or its uncertain status due to a pending legal battle, Trump promised to protect patients with pre-existing conditions.nn”I have also made an ironclad pledge to American family: We will always protect patients with preexisting conditions,” Trump said.nnHe added that the administration will “always protect” Medicare.nnTrump also reiterated the administration’s commitment to improving kidney care and eradicating HIV by 2030.nnIndustry reaction to speechnnFollowing the address, stakeholders weighed in on the president’s remarks, expressing both support and criticism of the administration’s direction on healthcare policy.nnElizabeth Mitchell, CEO of the Pacific Business Group on Health, told HealthLeaders that business leaders are primarily concerned about policy proposals that ensure drugmakers, payers, and providers “don’t use anti-competitive practices to gain market power and raise prices.”nn“Employers are fed up with high drug costs and high healthcare costs generally,” Mitchell said in a statement to HealthLeaders. “They’re doing everything they can to be effective purchasers on behalf of their employees, but they don’t have adequate negotiating leverage with monopoly drug manufacturers. We need policymakers to stop manufacturers from egregious pricing and anti-competitive practices.”nnRep. Greg Walden, R-Ore., Ranking Member on the House Energy and Commerce Committee, said he had not seen a president “lean in further” on “lowering health care costs.”nn”President Trump is committed to driving down the cost of unaffordable prescription drugs; he is committed to helping American families. This stands in stark contrast to the command and control view of many in the Democratic Party today,” Walden said in a statement.nnContrasting Walden’s remarks, Rep. Lloyd Doggett, D-Texas, Chairman of the House Ways and Means Committee, said Trump has “failed to do anything to actually lower prices for anyone.”nn”Instead of slashing prices, Trump slashes Americans’ healthcare. He seeks to terminate Affordable Care for millions, end protections for patients with pre-existing conditions, and wreck Medicaid, while promoting ‘junk insurance’ and claiming to have a secret replacement plan,” Doggett said in a statement.nnThe Campaign for Sustainable Rx Pricing (CSRxP), which includes America’s Health Insurance Plans and the American Hospital Association as members, tweeted its approval of Trump’s call for a plan to lower prescription drug prices.nn”President @realDonaldTrump is right to call on Congress to lower #drugprices and hold #BigPharma accountable,” CSRxP tweeted. “The American people are watching to see if lawmakers can rise above politics and the influence of #BigPharma to pass bipartisan, market-based drug pricing solutions.”nnJack O’Brien is the finance editor at HealthLeaders, a Simplify Compliance brand.nnOriginal 
In the January 23rd edition of the MLN Connects, CMS announced the release of a Comparative Billing Report (CBR) on Shoulder Arthroscopies for Medicare part B claims. This information can be vital for Orthopedic practices during the audit process. Data will be compared based on other providers in your state as well as nationwide. However, this information is not available publicly so you must login to make sure your contact information is up to date. You can also visit the