Jan 22, 2020 | Uncategorized
Medicare, the Affordable Care Act, and other issues are all hot topics being discussed in 2020. Below is more information regarding some of the big topics that are in talks right now or are in the process of change. Read the article below for more information on some of these medical issues.nnnIt’s 2020 and another year of health-related topics awaits us. What health issues will take priority? What buzzwords will we all be talking about? How might technology change healthcare?nnWe asked some experts to peek into their crystal balls and make a few predictions.nnThey tell us that how you get access to healthcare and how you pay for it will both be hot topics this presidential election year.nnIn fact, one expert says healthcare could help decide political winners and losers.nn“Whoever comes up with a plan that will work, is affordable, and something people can understand, that will push them ahead,” said Kurt Mosley, vice president of strategic alliances for Merritt Hawkins, a physician search, consulting, and research firm.nnMedicarenMedicare is front and center as we kick-off 2020.nnThat’s in part because “Medicare for All” is the single-payer option health plan being touted by two of the top Democratic presidential candidates.nnJeff Becker, the senior analyst for healthcare strategy at Forrester Research says there are also a number of bills in Congress looking to expand access to Medicare as a public option.nn“When you look at the polling numbers, our call is that Medicare for All will die in the court of public opinion and become Medicare Advantage for more,” Becker told Healthline.nnAffordable Care ActnThe Affordable Care Act (ACA), often referred to as Obamacare, will be in the courts again this year.nnIn December, a federal appeals court ruled that the health insurance law’s individual mandate provision was unconstitutional.nnHowever, the justices sent back to a federal district court in Texas the issue of whether other parts of the law could continue to exist without the mandate that requires everyone to have health insurance.nnLook for some sort of Obamacare case to wind up in the U.S. Supreme Court this year.nn“Our call is whether or not it goes to the Supreme Court, the ACA will survive because the individual mandate is severable,” Becker told Healthline.nnPrice TransparencynExperts say you’ll hear a lot of debate about price transparency, a move designed to increase competition and lower costs.nnPresident Trump signed an executive order in November that requires hospitals and insurers to publish their confidential, negotiated rates for treatments.nn“The reason this would be important is you’d be able to figure out what your out-of-pocket expenses would be” said, Becker.nnBut a coalition of hospital groups has filed a lawsuit to block the rule. They argue that the public disclosure of negotiated charges would create confusion about consumers’ out-of-pocket costs.nnThe order is scheduled to go into effect on January 1, 2021.nnLower Prescription Drug Pricesn“The thing about pharmaceuticals is, if you can’t afford them, they don’t work,” Mosley said.nnHe predicts the move to lower the costs of prescription drugs will again be on the front burner of the healthcare debate in 2020.nn“The problem is Medicare and Medicaid can’t negotiate prices with these drug companies,” Mosley told Healthline.nnThe House of Representatives has approved a bill that would do just that. The legislation also caps out-of-pocket expenses for people enrolled in Medicare Part D.nnHowever, the prognosis for this bill becoming law isn’t good.nnPolitical observers say the legislation won’t go anywhere in the Senate, and the White House has indicated the president would veto it.nnRepublicans in the Senate have crafted their own prescription drug price plan. The president has indicated he would sign this bill, but it would need to be approved by the Democrat-controlled House.nnAccess to Health Servicesn“One of the cross-cutting issues we see as a priority in 2020 is the social determinants in health disparities in our patients,” said Amy Mullins, MD, FAAFP, medical director for quality improvement for the American Academy of Family Physicians.nn“Patients need more than just access to a physician,” she told Healthline. “They need access to good food, safe places to live, to exercise, transportation, community resources, access to medication.”nn“If you don’t address those, it’s really difficult to treat your patients effectively,” she added.nnMullins says her group has an internal division called the Center for Diversity and Health Equity whose mission is to look at healthcare through that lens.nnVaccine HesitancynMullins also says the issue of vaccine myths is one you’ll continue to hear about in 2020.nn“We want to do more to counter the misinformation that’s out there around vaccines that may be holding some people back from getting what they need,” said Mullins.nnA recent study concluded that a lot of the false information is being spread on social media by a handful of anti-vaccine ad buyers.nn“We’re promoting vaccine education to physicians, their healthcare teams, patients, and communities,” Mullins said.nnA 2020 National Vaccine Plan is currently being developed by the Department of Health and Human Services’ Office of Infectious Disease and HIV/AIDS Policy.nnVapingn“Another of the big priorities for health providers in 2020 is vaping and e-cigarettes, ” Mullins said.nn“We really applaud and support the work the Centers for Disease Control and Prevention and the Food and Drug Administration is doing to try and get a handle on this crisis,” she said. “But these products target adolescents and we think marketing needs more regulation.”nnA study released last month from the National Institute on Drug Abuse reported that more teens are vaping marijuana.nnThat’s despite a lung illness linked to vaping that’s killed more than 50 people trusted Source nationwide.nnVirtual care visitsnOn the digital front, Becker predicts there will be aggressive growth in virtual care visits.nnThat’s where you interact with your doctor via text, video, or phone call.nnBecker’s group crunched the numbers after looking at outpatient visit data as well as talking to virtual vendors and tracking healthcare investments.nn“The result was 36 million net new virtual care visits in 2020,” he said.nnHe points to how employers and insurers are already embracing the concept. Amazon recently launched a pilot program called “Amazon Care,” a virtual clinic for its employees in Seattle.nnWalmart recently expanded its telehealth services to workers in Colorado, Minnesota, and Wisconsin with $4 online or video care visits.nnHumana has teamed up with “Doctor on Demand” to offer a virtual primary care plan at significantly lower monthly premiums.nn“Everybody is moving toward a model where we’re not using high-cost care centers like emergency rooms,” Becker said.nn“And consumers are demanding more cost-effective services, too,” he added. “In 2018, consumers took out $88 billion in personal loans just to pay for out-of-pocket medical costs.”nnOriginal article published on healthline.com
Jan 22, 2020 | Uncategorized
Vaping and E-cigarette use by young adults has grown over the past few years. While many are ignoring the effects of using these products, the CDC and CMS have released addendums regarding these products after the World Health Organization confirmed the side effects of vapes and e-cigarettes. Read below for more on these important updates and what new codes will be used in conjunction with vaping-related disorders.nnWe have all seen the stories in the news lately about the effects vaping and e-cigarettes are having on young adults. The implications cannot be ignored and considering how quickly the World Health Organization (WHO) has responded it only confirms our suspicions.nnIn December, the CDC and CMS published the full addenda regarding the use of the new emergency U code for e-cigarette and vaping associated lung injuries (EVALI). This new code, U07.0 [Vaping-related disorder] is to be used in conjunction with other established ICD-10 codes for the reporting of medical encounters for EVALI.nnRefer to the links for the full releases by the CDC including CMS links to further information.n
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Jan 15, 2020 | Uncategorized
Anthem and Cigna have released updates regarding the reimbursement updates and changes. These changes will go into effect in March 2020. For more information on the updates and the changes that may affect you, read below!nnAnthem sent out a Notice of Material Change (NOMC), dated December 1st, 2019. This is notice of Anthem changing the reimbursement for Advanced Practitioners (NPs and PAs), effective March 1st, 2020. Moving forward, Anthem will no longer reimburse based on the “incident to” rules and Advanced Practitioners will be reimbursed at 85% of the contracted rate. This comes as a 15% decrease in reimbursement for Advanced Practitioners. This also means that any Advanced Practitioners that have not been added to Anthem’s system will need to submit new provider applications.nnAll provider files must be finalized by 03/01/20 for providers to be reimbursed. If submitting 10+ providers, Anthem has offered a roster format to expedite the process. If submitting less than 10 providers, each file will need to be submitted via Availity for processing. Anthem has assured Welter Healthcare Partners that provider files will move quickly when submitting via a roster and there should be no concern for the effective date. If there are fewer than 10 providers to be submitted, then individual new provider applications need to be submitted through Availity as soon as possible. Advanced Practitioners do not require full credentialing unless an NP would like to be listed as a PCP, so these files should be processed more quickly; however, we are within the 90-day timeframe.nnTo summarize, Anthem is essentially making three distinct and important changes that will affect your practice:n
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- Anthem will no longer recognize and reimburse based on the “Incident to” rule. This includes all services rendered by any eligible provider, even if the services meet Medicare guidelines.
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- Anthem is requiring all Advanced Practitioners (NPs and PAs) to be processed in their system, effective March 1st, 2020. Per Anthem, all Advanced Practitioners are eligible to submit claims directly to Anthem so new applications must be submitted if they are not loaded in the system.
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- All services rendered by Advanced Practitioners will be reimbursed at 85% of the applicable contract rate. This will come at a 15% decrease to your current contracted rate.
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nIf you need help or have additional questions regarding these reimbursement changes, please don’t hesitate to contact us!n
Jan 15, 2020 | Uncategorized
Last week, we briefly described the X modifier series and when to substitute these new modifiers. Below are a few scenarios from the NCCI policy manual you can refer to when using these modifiers.*n
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- The CCI bundle involving column 1 code 45385 (Flexible colonoscopy with removal of tumor[s], polyp[s], or lesion[s] by snare technique) and column 2 code 45380 (Flexible colonoscopy with single or multiple biopsies) with one of the four X modifiers. However, note the exact CCI guidance: “The use of modifier XS is only appropriate if the two procedures are performed on separate lesions. Use of modifier XE is only appropriate if the two procedures are performed at separate patient encounters. The documentation shall not be reported with a code for the same lesion”.
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- Generally, providers shall not report more than one physical medicine and rehabilitation therapy service for the same 15-minute time period. You’ll find that some CCI edits pair a timed CPT code with another timed, or non-timed, CPT. These edits can be bypassed “with modifier 59 or XU if the two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter”.
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- The primary graft and skin substitute codes are mutually exclusive since only one type of graft or skin substitute can be used at a single anatomic site. If multiple sites require different types of grafts, use modifier XS to indicate the different sites.
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- You should not report HCPCS code J3471 (Injection, hyaluronidase, ovine, preservative-free, per 1 USP unit [up to 999 units]) with more than 999 units of service (UOS). If you report more than 999 units of the product described by J3471, you “may report HCPCS code J3471 on more than one line of a claim appending modifier XU to additional claim lines and should report no more than 999 UOS on any one claim line”.
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- You can report a diagnostic procedure in cases where the procedure’s findings necessitate a therapeutic response. “A diagnostic procedure is performed on a 60-year-old male complaining of chest pains. Due to the findings, a physician’s decision is then made to perform a therapeutic/surgical procedure. When the diagnostic cardiac angiography leads to a therapeutic angioplasty, use XU as the modifier.”
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n*As with all code reporting, be sure to check with individual payers on their policy regarding the X modifier series.
Jan 10, 2020 | Uncategorized
Welter Healthcare Partners is sharing the new 2020 CPT coding updates! Below you will find the new CPT codes that took effect on January 1st. Read below for more on these updates. Please note that this article is not an all-inclusive list of the updates. Be sure to review the CPT 2020 book for the complete descriptions of the changes.nnn2020 CPT Coding Updates nnWritten By: Ginger Avery, CPC, CPMA, CRC Coding & Compliance Manager nnIt’s that time of the year again! The new CPT®2020 code changes take effect January 1st and are based on input from clinicians, medical societies and the greater health care community. Understanding the myriad of upcoming changes is crucial to obtaining the proper reimbursement for your services! The changes for 2020 address a number of interrelated issues. Clinical practice and technology have evolved and several issues required much needed CPT expansion and clarification. CPT®2020 offers changes that affect nearly every specialty.nn*Please note, this article is not an all-inclusive list; review your CPT®2020 book for complete descriptions of all changes. Appendix B on page 816 of AMA’s CPT®2020 provides a summary of additions, deletions, and revisions. Watch for green text throughout the codebook for new information! nnThe American Medical Association’s (AMA’s) 2020 update of the CPT code set comprises 394 code changes, including 248 new codes, 71 deletions, and 75 revisions. Aside from anesthesia, all sections of CPT received changes in codes and guidelines.nnHighlights of the most significant changes are as follows: nnIntroduction Changes (see CPT®2020 pg xvi): n
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- Code Symbols update: “…even though the PLA section is located at the end of the pathology and laboratory section of the codes set, a PLA code does not fulfill Category I code criteria.”
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- Add-on Codes concept updated: “…when the add-on procedure can be reported bilaterally and is performed bilaterally, the appropriate add-on code is reported twice…Do not report modifier 50 in conjunction with add-on codes…See the definitions of modifier 50 and 51 in Appendix A.”
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nChanges to the Appendices (see CPT®2020 Pg 809) nnAppendix A: Modifiersn
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- Modifier 50: This modifier should not be appended to designated “add-on” codes (see Appendix D). If an additional or supplemental procedure is performed bilaterally, report the add-on code twice using the RT and LT modifiers to indicate laterality, rather than modifier 50.
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- Modifier 63: Should not be appended to any CPT codes listed in the Evaluation and Management Services, revised to include medicine section codes that can be reported.
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nAppendix E: CPT Codes Exempt from Modifier 51nnUpdated list of CPT codes exempt from modifier 51nnEvaluation and Management Changes (see CPT®2020 pg 38-56) n
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- Preventive
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- Do not report HBAI’s with Behavior Change Interventions
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- Non-Face-to-Face Services
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- Telephone Services (99441-99443)
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- Remote Physiologic Monitoring Treatment Management Services (99457-99458) was revised to be time-based.
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- E-visits: Six new CPT codes for reporting a range of digital health services including e-visits through secure patient portal messages.
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- Time-based codes 99421, 99422 and 99423 have been created to describe patient-initiated digital communications with a physician or other qualified health professional
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- 98970, 98971 and 98972 represent patient-initiated digital communications with a nonphysician health professional
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- New codes 99473 and 99474 allow reporting self-measured blood pressure monitoring (pg 42).
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- CPT 99473 is used to report patient education, setup, and device calibration.
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- To report 99474, a minimum of 12 recordings must be reviewed, and the provider must render an interpretation that includes average systolic and diastolic pressures and communication with the patient on the treatment plan.
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- Chronic Care Management (CCM) guideline update.
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- Transitional Care Management (TCM) guideline update.
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nSurgery Section Updates nnIntegumentaryn
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- The guidelines for intermediate and complex repairs (12031 – 13160) have been revised to provide a clearer description of what is required for undermining. Intermediate repairs include limited undermining, CPT describes as “a distance less than the maximum width of the defect, measured perpendicular to the closure line, along at least one entire edge of the defect.” Complex repairs include extensive undermining, CPT describes as “a distance greater than or equal to the maximum width of the defect, measured perpendicular to the closure line along at least one entire edge of the defect.”
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- New guidelines are also added in each of the subsections for breast procedures (19000 – 19303). An extensive review of these subsections is required. In addition, code 19304 is deleted due to low utilization. Parenthetical notes are added to direct you to the correct codes for this service.
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- New autologous grafting codes have been created. Code 15769 is reported for soft tissue harvested by direct excision. Codes for the harvesting of fat by liposuction are reported based on anatomic site and amount of fat removed. Harvesting codes are reported by the recipient site of the graft, not the donor site.
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- Codes 15771 and +15772 are reported for fat harvested via liposuction for defects of the trunk, breasts, scalp, arms, and/or legs. Code 15771 includes 50 ccs or less, and +15772 is an add-on code for each additional 50 ccs or part thereof.
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- Codes 15773 and +15774 are reported for fat harvested via liposuction for defects of the face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet. Code 15773 includes 25 ccs or less, and +15774 is an add-on code for each additional 25 ccs or part thereof.
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- Codes for the excision for chest wall tumors (19260, 19271, 19272) are deleted and replaced with new codes in the Musculoskeletal System section (21601, 21602, 21603).
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nMusculoskeletal System nnNew codes have been created to report needle insertion into a muscle(s) without injection. Code 20560 is reported for one to two muscles, and 20561 is reported for three or more muscles.nnSix new add-on codes (20700-20705) are now available to report the manual preparation and insertion of drug delivery devices and the removal of the devices. The manual preparation includes the mixing of agents and placing them on the delivery device such as nails, beads, or spacers. Parenthetical notes are included to indicate the primary codes with which the add-on codes can be reported.nnRespiratory Nine nasal/sinus endoscopy codes (31233, 31235, 31292, 91293, 31294, 31295, 31296, 31297, and 31298) are revised. Parenthetical notes have been added for more consistent code descriptors and to clarify use.nnCardiovascular n
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- Codes for pericardiocentesis (33010, 33011, 33015) are deleted and replaced with new codes. Pericardiocentesis is no longer coded based on initial or subsequent service. There is now one code for pericardiocentesis (33016), which includes imaging guidance when performed; and there are three new pericardial drainage codes:n
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- 33017 is for pericardial drainage with the insertion of an indwelling catheter on patients 6 years and older. The procedure includes fluoroscopy or ultrasound guidance when performed.
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- 33018 is for pericardial drainage with the insertion of an indwelling catheter on patients 5 years old and under, or patients of any age with a cardiac anomaly. The procedure includes fluoroscopy or ultrasound guidance when performed.
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- 33019 is for pericardial drainage with the insertion of an indwelling catheter when computed tomography (CT) guidance is used. This code is not age-specific.
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- Ascending aorta graft code 33860 is deleted and replaced by two new codes: 33858 and 33859. When the procedure involves aortic dissection, use 33858. If performed for aortic disease other than dissection, use 33859.
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- The transverse arch graft code (33870) is deleted and replaced with 33871. The descriptor is revised to better describe the service as it is performed now.
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- Pacers or Implantable Defibrillators & device evaluation code instructions
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nDigestive System nnThe descriptors for internal hemorrhoidectomy codes 46945 and 46946 are revised to include “without imaging guidance.” Category III code 0249T is deleted and replaced with Category I code 46948 to report an internal hemorrhoidectomy by transanal hemorrhoidal dearterialization, which is a less invasive procedure than the traditional hemorrhoidectomy.nnNervous System nnInjection, Drainage or Aspiration updates (see codes 62270-62273 & 62328-62329)nnMedicine Section Changes nnNew influenza vaccine code (90694) to report a quadrivalent, inactivated, adjuvanted, preservative-free vaccine that is administered intramuscularly. See specific updates in CPT®2020 for the following bullets:n
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- Implantable, Insertable, and Wearable Cardiac Device Evaluations
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- New add-on code for myocardial strain imaging 93356
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- Cardiac Catheterizations (93451 – 93462)
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- Arterial & arterial-venous studies (93925-93990)
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- DIY Blood pressure monitoring (99473 – 99474)
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- Counseling/Risk Factor Reduction
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nUpdates for health and behavior assessment and intervention services: New codes 96156, 96158, 96164, 96167, and 96170, and add-on codes 96159, 96165, 96168, and 96171 for health and behavior assessment and intervention services will replace six older codes. According to the AMA, this update is intended to “more accurately reflect current clinical practice that increasingly emphasizes interdisciplinary care coordination and teamwork with physicians in primary care and specialty settings.”nnSignificant changes for reporting long-term electroencephalographic (EEG) monitoring services (95700-95726): Monitoring the electrical activity of the brain is critical to diagnose epilepsy. Four older codes have been deleted to make way for 23 new codes for long-term electroencephalographic (EEG) monitoring services. According to the AMA, the new codes provide better clarity around the services reported by a technologist, a physician, or another qualified health care provider.nnAs a reminder, with ALL services, the purpose of documentation is to tell an excellent story about each individual encounter. Why is the patient here today (what is the presenting problem), what are the observations, what is the clinical impression/plan of care? Focusing documentation on clinically relevant details for the unique services provided creates clear notes that help to support excellent patient care, creates clear collaboration between professionals and supports medical necessity for the services reported.nn Welter Healthcare Partners’s team of expert coders can help clinicians report the correct codes and ensure proper reimbursement for their services. We provide ongoing education and update our clients with changes to codes and reporting requirements, as well as provide documentation pointers to ensure clinician documentation is legible, complete, and accurate to help with timely reimbursement. Coding compliance plans, external audits, and annual clinician education is required by the ACA! Contact us today to get started!
Jan 10, 2020 | Uncategorized
It has been several years since CMS released the X modifier series, are you using these correctly or not at all? In an end of year survey, published in Part B News, 78% of respondents said they had reported an X modifier in 2019. The creation of the X modifier series is to report with greater specificity the scenarios when just 59 had been used in the past. Effective July 1, 2019, MAC’s now process modifier 59 when used on either column 1 or 2 codes in addition to the most appropriate X series modifier.nnHere is a great scenario for the use of XU [Unusual non-overlapping service]:nnIf a peripheral nerve block injection is performed for postoperative pain management on the same date as the anesthesia code used for the procedure, the use of modifiers XU is appended to the peripheral nerve block injection to indicate that it was used for the postoperative pain management.nnFor other great scenarios directly from CMS, click here. It has great detailed information about these modifiers and some additional scenarios to help.nnAnother great article on this topic was released in the December 30th issue of Part B News by Jim Dresbach, click here to read!
