CMS Seeks Feedback on Aligning, Simplifying Coding and Documentation Requirements
CMS is requesting feedback on ways to reduce the administrative and regulatory burden with aligning and simplifying coding and documentation requirements. The comment period will close on August 12, 2019, at 5:00 p.m. EDT.nnOn June 11, CMS published a Request for Information (RFI) as part of its Patients Over Paperwork initiative to collect public input on ways to reduce unnecessary administrative and regulatory burden.
nnThis is not the first time CMS has sought feedback on methods to reduce administrative burden. Through previous listening sessions and RFIs, CMS collected thousands of comments and is actively working on addressing those comments deemed actionable. The current RFI aims to collect feedback on several specific topics that have not yet been addressed. These include:n
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- Aligning Medicare, Medicaid, and other payer coding, payment, and documentation requirements
- Enabling feedback and data sharing to support patient care and the clinician-patient relationship
- Recommendations for when and how CMS issues regulations and how CMS can simplify rules and policies for beneficiaries, clinicians, and providers
- Streamlining reporting and documentation requirements or processes to monitor compliance
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nRespondents should provide clear, complete comments and should include, when possible, data and specific examples. The comment period closes on August 12, 2019, at 5:00 p.m. EDT.nnOriginal article posted on revenuecycleadvisor.com
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nnIt seems nearly everyone believes U.S. health care needs some transformative change to improve quality, expand access, or lower costs. Many of the contemporary approaches toward that change involve making it easier for patients to see doctors, particularly primary care doctors. While that seems intuitive, we think it is the wrong path.nnImagine it’s 1970 and commercial bank executives are deciding how to help their customers get the banking services they need. One executive remark, “Most of our customers engage with us through our bank tellers–even if they’re later referred to someone behind a desk. To help our customers get the banking services they need, we must make it easier for them to get in front of bank tellers.”nnWhether or not discussions like that really happened, that wasn’t the direction banks took. Instead, banks introduced automated teller machines to improve customer service. As a result of this unshackling of banking from tellers, 25-year-olds today find it unimaginable that their parents contorted their schedule to get cash during the Monday to Friday, 9 a.m. to 3 p.m. window. In the age of Venmo, they can’t imagine the need for cash in the first place.nnAnd yet, fifty years later, health care leaders continue to discuss how to get more patients in front of primary care providers, or in general to make it easier for patients to see doctors. The value-add from the technical knowledge and skills of primary care and specialist clinicians is greater than that from bank tellers, but the principles limiting the value of this strategy are the same. True transformations come from enhancing productivity, and productivity is enhanced by decreasing personnel effort, not increasing it.nnIf we continue to define health care as a service that happens when patients see doctors, we limit our possible productivity gains.nnWriting in 
We think the resistance reflects our social conventions rather than our technical limitations. The technical challenges of safely introducing driverless cars are far more daunting than the technical challenges of introducing bots to manage hypertension and diabetes, yet the prospect of driverless cars seems to be awaited with excitement. We need to solve three problems:nnFirst, the insurance industry—government and commercial—must get better at its job. Because they are ill-equipped to determine whether care was truly needed or appropriately delivered, they use proxy process measures: Was the care face to face? Was the right amount of time spent or the right number of facts documented? Was the right kind of clinician present? Without a measure of what’s good, insurers have found it easier to insist that care be delivered in traditional ways. It’s hard to explore new and potentially better models of care when only old approaches get reimbursed.nnSecond, state-based regulation of insurance and clinician licensure must be replaced by a system that recognizes that health care is not always best delivered locally. Facilitated self-service creates efficiencies across state lines. It’s likely that occasionally some of Wyoming’s 600,000 residents would benefit from care delivered by someone outside the 1,000 physicians practicing in that state—perhaps by a bot with second-line back up from a nurse or a physician elsewhere. State licensure of physicians and insurance regulations reflect federalist principles harder to justify in a connected world.nnThird, we should require the same standards of safety and efficacy for automated approaches to health care that we have come to assume for the safety of pharmaceuticals. Whether that regulation comes from the FDA or elsewhere, it needs to be ramped up to address the volume of potential new approaches. Even if we think a bot can help manage hypertension, it doesn’t mean any bot can do that. The organizations that credential clinicians might find they are well suited to credential robots.nnIf there is a fourth problem, it is our sense of nostalgia. Norman Rockwell’s paintings of what he saw as wholesome and right reflected a time when doctors attended to the whole family, knew some from the cradle and some into the grave, and were paid with a basket of eggs. Facilitated self-service health care doesn’t challenge the appeal of this image, but it does shift it toward those elements of care that can’t as easily be handled by a machine.nnThe health care changes we want, or at least the opportunities to try them, are held back by a combination of technical limitations and social conventions. But our social conventions present greater obstacles. The lesson from other industries is that transformational change requires productivity change. And in health care, that means we must find ways to move past approaches to facilitate care with doctors toward approaches that facilitate care without them.
We continue to see the risk adjustment model being implemented by several large hospital groups and the sooner small practices catch in the better off their business models will be. So why is this so important?nIt’s simple, Centers for Medicare & Medicaid Services (CMS) utilizes this in the analysis of Medicare Advantage patients and that ultimately is a major factor when it comes to your reimbursements. What can your practice do to avoid missed opportunities?nThe first step to the implementation of anything new is education. Make sure your providers are aware of HCC’s and how they play a roll in risk adjustment factor calculations. Welter Healthcare Partners is excited to now offer our clients Risk Adjustment auditing and educations to assist you and your team with the implementation of HCC’s in your documentation, billing, and coding.
One of the models focuses on a more general population, while the second model is for advanced primary care practices that typically provide hospice or palliative care services and want to take responsibility for high-need, seriously ill beneficiaries who currently lack a primary care practitioner and/or effective care coordination, according to a CMS fact sheet on the models.The model involves a potential downside risk of 10%, and an upside risk or bonus of 50%, depending on patients’ outcomes, and performance would be measured on “risk-adjusted hospitalizations” or “the ability to keep patients healthy at home,” Adam Boehler, director of the Center for Medicare & Medicaid Innovation (CMMI), which developed the models, said at a press briefing. “For example, doctors that earn $200,000 today could earn up to $300,000 if their patients stay healthy.” For 2020, the CMS has identified 26 regions where practices can participate.The CMS says that the model’s monthly per-patient payments will help doctors stop worrying about their monthly revenue cycle. However, as Miller noted in an article, “at the same time that Primary Care First eliminates the current E/M [evaluation and management] payments for face-to-face office visits for attributed patients, it creates a brand-new $50 fee for each face-to-face office visit, which is about half as much as the average amount primary care physicians currently receive from Medicare for office visits.””Based on the current average frequency with which Medicare beneficiaries make primary care office visits, this means that more than 40% of a typical practice’s payments would still be tied to face-to-face visits. As a result, if the practice is able to care for patients effectively with fewer office visits, it will lose revenue and it could be unable to cover its operating costs,” he wrote.nnLACK OF RISK ADJUSTMENTnAnother problem with the program is that a primary care practice would receive the exact same monthly payment for a patient regardless of how sick or healthy they are, Miller said. “Since an individual patient who has higher needs will require more time and resources from the practice than other patients, a practice that is caring for that patient will have to reduce the time and resources it devotes to other patients if the payment is the same.”And in addition to those issues, since Medicare payment programs are expected to be revenue-neutral compared with the current budget, “the payment is intended to be the same as what the practice is currently getting,” although the practice will be expected to provide more services than before, including 24/7 patient access and integrated behavioral healthcare, Miller said.Miller is a member of the Physician-Focused Payment Model Technical Advisory Committee (PTAC), which advises the CMS on Medicare alternative payment models. “In general, I think there’s been a lot of concern for a long time about [the] need to provide better support for primary care, and most payers in the country have been trying to do some kind of medical home programs for quite a while,” he said. “Medicare has been fairly slow to the game on that.”In particular, Miller is disappointed that the CMS hasn’t shown much interest in pilot-testing the payment models that PTAC has recommended. “With PTAC, two proposals [were submitted] for primary care, and we reviewed them and recommended they be tested and implemented … It’s been a long time since the recommendations were made, and the surprising thing to me was that the [Primary Care First] model that was announced by [the CMS] really didn’t look at all like the models recommended by PTAC.”nnROOM FOR IMPROVEMENTnThere are ways that Primary Care First can be improved, Miller said. For starters, “rather than creating a whole new set of office visit payments, what primary care practices have asked for is to get all or most of their payments as a flexible monthly payment so it’s not tied to office visits.”In addition, the monthly payments should be higher for patients who require more care. “If you have more diseases and more care challenges, you’re going to require more attention from your primary care physician,” said Miller. “The way that happens today is more office visits … but we don’t want to pay more only if they come to the office.”When asked during a press briefing about the Primary Care First model, CMS administrator Seema Verma said the agency was trying to give physicians a variety of options. “What we tried to do is recognize that providers are in different places in terms of their ability to take on risk,” she told MedPage Today. “What we’ve tried to do in this model is provide different options … Some providers may say ‘I want to take full risk on,’ so we’ve allowed for that option.””What we want to do in primary care is have them focus less on revenue cycle … and actually be able to focus on patients,” she continued. “The requirements around 24/7 [availability] — the idea there is that it’s based on some work we’ve already done in primary care and some of [it is] ‘lessons learned’; we’re looking at what we know works.”Some providers differ with that assessment. “I know it was well intentioned, but [the] CMS seems not to understand the day-to-day mechanisms of [how] primary care practices work,” Jean Antonucci, MD, a family physician in rural Maine and the author of one of the alternative payment model proposals that was recommended by PTAC, said in an email. “It is really virtually impossible to figure out how much revenue a practice will receive.””Supposing that my patients are well taken care of so I am placed in the lowest [payment] category of $24 a month; it’s very difficult to [keep patients] out of the hospital for $24 a month, but I might be put in that category because I did a good job. So no good deed will go unpunished,” she said.In her own proposal, she considers the cost of an hour’s worth of phone calls — 15 minutes, four times a month — from a practice to a particular patient. “A [medical assistant] is $15/hr. easy, but often the doctor must be involved, or an RN, and that is $40-$150 per hour, plus they need the driver’s license form or the forms for oxygen … We end up with whining by doctors about not being paid, while payers and pundits complain we want to nickel-and-dime them to death.”nnOTHER POSSIBLE APPROACHESn
Primary Care First’s early reviews “reveal that longstanding conflicts remain between, on the other hand, budgetary savings and administrative feasibility goals and, on the other hand, more ambitious desires in parts of the medical community redesign care to elevate the role of effective primary care (regardless of the short-term costs),” Tom Miller, JD, resident fellow at the American Enterprise Institute, a right-leaning think tank, said in an email. “Perhaps more medical outcomes per se could be improved by simply paying primary care doctors more, but that assumes away the political food fight it would require to get there.”A more straightforward approach to “subsidize patients more directly to find and receive the care that they could choose to receive would upset providers either benefiting from the current system or imagining that they could be winners in the next round of political reimbursement roulette, labeled ‘value-based,'” he added.Gail Wilensky, PhD, senior fellow at Project HOPE in Bethesda, Maryland, and a former CMS administrator, said in an email that the difficulty with the model “seems to be the amount paid is too small and too unreliable … That is certainly consistent with the ongoing CMS attempts. It is certainly reason to be skeptical although the results will only become clear after it is tried, assuming [the] CMS goes forward with it … It has been discouraging how difficult it has proven to be to affect change in this area.”nnOriginal 
The clock is ticking, and you’re trying to select the right E/M level from a drop-down menu in the EHR. Choose a level that’s too high, and you run the risk of post-payment audits and recoupments. Choose one that’s too low, and you may lose revenue to which you’re entitled. You decide just to trust your instincts and go with a code that feels right so you can move on to the next patient.nnChoosing an E/M code based on a gut feeling is one of the biggest mistakes a physician can make, says Sonal Patel, CPMA, CPC, a healthcare coder and compliance consultant with Nexsen Pruet LLC, a business law firm in Charleston, S.C. Payers and auditors use a quantitative scoring process that requires specific elements (i.e., history, exam, and medical decision-making [MDM]—or time spent counseling and coordinating care) for each E/M level.nnIf physicians don’t document these elements adequately—or the elements they document don’t make sense given the patient’s presenting problem (e.g., performing a comprehensive exam for a patient with a sinus infection)—payers and auditors may down-code the service or even conduct a more in-depth audit that could expose additional documentation vulnerabilities, she adds.nnIt’s equally risky to report the same E/M level for all patients with the same diagnoses (e.g., diabetes or congestive heart failure) without first considering medical necessity—a trap into which many physicians fall because they assume all patients with the same diagnoses generally require the same work, says Toni Elhoms, CCS, CPC, director of coding and compliance at Welter Healthcare Partners , a healthcare consulting company in Arvada, Colo. “In reality, every single visit could be a different level based on the documentation and circumstances of the encounter,” she says.nnFocus on quality E/M documentation—and the dollars will follownnKnowing what documentation is required for each E/M level is paramount. For example, the history, exam, and MDM must meet or exceed certain requirements for all new patients. The only exception is when the physician selects the E/M level using time as the controlling factor. In this case, documentation must indicate that the physician spent more than 50 percent of the encounter face-to-face with the patient and/or family providing counseling and/or coordination of care. The physician must also explain the specific services rendered and the reasons for them.nnOnly two of three key components must meet or exceed certain requirements for established patients unless the physician bills based on time. Elhoms provides an E/M scoring guide that includes a visual depiction of documentation requirements for each specific E/M level based on whether the patient is new or established.nnSound confusing? Experts agree that even the most experienced medical coders have difficulty translating physician documentation into an accurate E/M code. They cite several reasons why E/M coding is so difficult for physicians—lack of formal training on E/M guidelines, complex documentation requirements that don’t align with clinical practices, and the subjective nature of the MDM component.nnWe’ve asked our experts to share their best documentation tips to ensure accurate E/M reporting. Here’s what they said.n
Does your practice screen patients for risk factors like smoking, alcohol or drug use? Do you know the correct coding for use patterns? According to section guidelines by the AMA, “…used to report services provided face-to-face by a physician or other qualified health care professional for the purpose of promoting health and preventing illness or injury. They are distinct from evaluation and management (E/M) services that may be reported separately with modifier 25 when performed. Risk factor reduction services are used for persons without a specific illness for which the counseling might otherwise be used as part of treatment.”nnThis is especially helpful when we look at codes 99406-99409 and incorporate this into your telemedicine services menu. Welter Healthcare Partners recently teamed up with CDPHE for a two-part webinar series on the coding and billing for these important codes and how school-based health centers can take advantage of the services they support.nn n
Even as some important questions remain unanswered, the CMS Primary Cares Initiative is generating a lot of excitement. Observers say it opens the door to more competitors for healthcare incumbents.nnThe shift to value-based care has sputtered a bit in the past two years, as hospitals and health systems have waited to see what innovative reforms the Trump administration would push across the healthcare policymaking finish line.nnDespite a litany of attempts—and two years of a Republican-controlled Congress—the administration has neither repealed nor replaced the Affordable Care Act and the value-based payment provisions embedded within it. Even with its individual mandate neutralized and its constitutionality under judicial review, the ACA remains law, and officials in the Centers for Medicare & Medicaid Services are using the ACA’s authority to roll out a potentially transformative undertaking: the CMS Primary Cares Initiative.nnThat initiative, industry stakeholders say, is poised to kickstart value-based care in Medicare and beyond, ushering in a new wave of consumer-centric competition that could help to shake off some healthcare providers’ risk aversion.nn”There was a sense that things were flattening out. It wasn’t going backwards. It wasn’t going down. It just was not progressing as fast as we all had hoped,” says Norman H. Chenven, MD, founding CEO of Austin Regional Clinic in Texas and vice chairman of the 
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Employers are increasingly focused on improving access and quality of care for their workers, according to a new survey.nnWithin the next three years, nearly half of employers plan on implementing high-performance networks (HPN), centers of excellence (COE), onsite or nearby health centers and accountable care organizations (ACO) as ways to provide quality and affordable healthcare options, according to a Willis Towers Watson (WTW) survey released Wednesday morning.nnEighty percent of respondents intend on having COEs within a health plan, a 29% jump year-over-year, and the number of employers who plan on including HPNs more than doubled to 65%.nnBy 2020, almost 40% of employers are looking at opening a health center at their offices, while more than 25% plan to offer one near their facilities.nnThese trends have gained momentum in recent years, as more than 80% of employers with an onsite or near-site health center reported that the move has “succeeded in improving employee access to convenient health care services,” “enhancing employee productivity and bringing absenteeism under control,” while also “delivering and promoting preventive health screening and services, getting ahead of medical issues through early detection and by instilling healthy habits.”nnThe survey also shows that employers are increasingly more concerned with quality of care provided than cost savings as the “most important feature” when considering an HPN.nnSandy Ageloff, managing director, west region health and benefits consulting leader, told HealthLeaders that the survey results indicate that the shifting thought process among employers is being driven by four major paint points.nnThese include the need for better care access, especially around mental health services for employees, providing high quality care, making care cost effective, and concerns about system complexity.nn”I think employers have done a lot to try to improve cost and quality, but what we’re realizing is that employees and their family members are challenged to understand all of the various pieces of the puzzle,” Ageloff said. “Employers are now embracing the need to say, ‘You need to help people navigate through what we’ve done to create beneficial, high-quality programs that provide affordable costs.'”nn
Now that we are all familiar with ICD-10 it’s time that we start focusing more on specificity when it comes to diagnosis. It’s not just import for patient charts, with HCC becoming the new standard and payers tracking things like readmissions it’s becoming more important than ever for Coders to capture as much in their code selection as possible.nnICD-10 includes a classification system implemented to capture data, which previously was not tracked. Classifications such as “underdosing of drugs” can prove to be vital when readmission rates are not only tracked but also could affect a practice’s reimbursements. As coders, it’s not only important that we extrapolate this information from the documentation but also code why the drug was not taken correctly or, in some cases, not at all. Classification codes T36-T50 (utilizing a fifth or sixth character of “6”), deals with specific drug underutilization while Z codes Z91.12- Z91.19 classifies the patient’s non-compliance with medical treatment and regimen. Z codes should, when known, be accompanied by the correct underdosing code to help account for intent.nnThe Journal of AHIMA wrote about this back in 2016, however this topic will continue to become more relevant as Risk Adjustment Models are adapted by more practices and payers.nn
Colorado Gov. Jared Polis stood outside of Denver Health Medical Center almost a month ago laying out his “roadmap” to save people money on health care.nnAs the Boulder Democrat ticked off his list of plans, both short term and long term, it quickly became apparent that most of the governor’s ideas to lower health care costs in Colorado weren’t possible unless state lawmakers passed a series of bills.nnDemocrats and Republicans have come together to create the beginnings of a 
nnThis bill would require “health insurance carriers, health care providers, and health care facilities to provide patients covered by health benefit plans with information concerning the provision of services by out-of-network providers and in-network and out-of-network facilities; outlines the disclosure requirements and the claims and payment process for the provision of out-of-network services; requires the commissioner of insurance, the state board of health, and the director of the division of professions and occupations in the department of regulatory agencies to promulgate rules that specify the requirements for disclosures to customers, including the timing, the format, and the content and language in the disclosures; establishes the reimbursement amount for out-of-network providers that provider health care services to covered person at an in-network facility and for out-of-network providers or facilities that provider emergency services to covered persons; and creates a penalty for failure to comply with the payment requirements for out-of-network health care services.nnRead the rest of the 
nnThe bill would direct state agencies to recommend a plan that would compete with existing private insurance plans and those offered on Colorado’s healthcare exchange. Another Senate vote sends the study bill to the governor. It’s already cleared the House on a bipartisan 46-17 vote.nnBackers say it’s designed to curb some of the nation’s highest insurance premiums in mountain and other rural areas. Fourteen of Colorado’s 64 counties have just one insurer for the individual market, and monthly premiums there can be $500 higher than in metropolitan Denver.nnThe so-called “public option” bill is one of several measures advocated by Polis to reduce health care costs and increase accessibility for Colorado residents. In Washington state, Democratic Gov. Jay Inslee has called for a state-based public option health insurance plan that he has called a “step toward universal healthcare.”nnPolis’ campaign for office stressed a variety of strategies for achieving universal coverage.nnThe first-term governor already has signed a hospital price transparency bill into law.nnMajority Democrats in the Legislature are expected to send him bills to create a state reinsurance program to help private insurers lower premiums; a prescription drug price transparency bill; and a bill to get the federal government’s permission to import cheaper prescription drugs from Canada.nnThe public option legislation directs the Department of Health Care Policy and Financing and the Department of Regulatory Agencies to present a proposal in November. The plan would assess costs, funding sources, necessary federal permissions and funding, consumer eligibility and who in government would run a plan.nnSupporters say enrollment could begin in 2020 and a plan could start operating in 2021. Sponsors include Sen. Kerry Donovan and Rep. Dylan Roberts, both Democrats, and Republican Rep. Marc Catlin.nnDonovan noted Tuesday that too many residents in her own district, which includes Aspen, Vail and Glenwood Springs, have to choose between health insurance and paying mortgages or other family expenses.nnRepublican Sen. Jim Smallwood, an insurance broker, questioned the wisdom of having government step in as a competitor. He noted that high rural premiums persist and are rising under a state health insurance exchange adopted under the 2010 Affordable Care Act.nn”Introducing the concept of a public cure for what is broken in Obamacare seems hypocritical,” Smallwood said.nnOriginal 
n the Code Spotlight, Welter Healthcare Partners aims to profile and discuss practice applications of the code, as well as pertinent guideline reminders. Allograft Coding 2019 saw several changes to CPT, three codes that were added to the Surgery code set are for Allografting.nnCodes 20932, 20933 and 20934 all include templating, cutting placement and internal fixation, when performed.n
nnFor example, say an internist performs an annual wellness exam and addresses a skin lesion during the same visit. If the physician doesn’t append modifier -25 (significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) to the evaluation and management (E/M) service for the lesion, most payers will disregard the E/M service and only pay for the annual wellness exam, says Elhoms.nnAppending a modifier when it isn’t warranted can also be costly. For example, an internist owns their own radiology equipment. If they append modifier -26 (professional component only) to each radiology service, they actually miss out on revenue, depending on the service, says Elhoms. For example, when appending modifier -26 to the CPT code for chest x-ray, single view (71045), physicians could lose approximately $13 for every test performed.nnElhoms cites the case of an internal medicine practice with its own radiology equipment that saw an immediate 60 percent increase in reimbursement simply by removing this modifier from the radiology CPT codes it reported.nnOn the other hand, when a physician incorrectly appends a modifier and subsequently receives payment, they could be subject to a post-payment audit. “I’ve seen so many recoupments regarding inappropriate use of modifier -25 that have put private practice physicians out of business,” says Elhoms. “There’s a false sense of security when it’s paid. Recoupment requests can come out of nowhere.”nnElhoms knows of one family medicine practice that couldn’t recover from a $250,000 recoupment after a payer audited the practice’s use of modifier -25 on E/M office visit codes when providers rendered osteopathic manipulation treatment (OMT) during the same encounter.nnThe payer alleged that the documentation didn’t support a significant and separately identifiable service, and the payer felt the OMT was part of the typical work associated with the E/M code and shouldn’t have been paid separately, she says.nnIs there anything physicians can do to collect the payment they deserve while also avoiding compliance risk? Here are six tips experts recommend:nn1. Know your payer policies.nJust because one payer accepts a modifier doesn’t mean all will, says Michael Miscoe, JD, founding partner of Miscoe Health Law LLC in Central City, Pa. For example, one payer might accept modifier -25 in all instances consistent with the CPT definition of “significant, separately identifiable” while another might not permit it at all for certain services (e.g. when a physician reports an E/M code in addition to a code for a pain management injection).nnTake the time to identify the modifiers each payer does—and doesn’t—recognize. “Check each payer’s medical policies for service-specific as well as general policies regarding separate reporting,” says Miscoe.nn2. Hire a certified coder.n
“Ideally, you would have at least one person in-house who can assist with modifiers and be proactive about monitoring denials and providing education,” says Elhoms. Another option: Keep a trusted compliance consultant on stand-by as questions arise, she adds.nn3. Focus on clinical documentation.nFor example, when physicians report modifier -25, their documentation must support the history, exam, and medical decision-making for two separate services, says Elhoms.nnThink of each service as a separate encounter even though they’re rendered during the same visit, she adds. For modifier -59 (distinct procedural service), documentation must support a different session, different procedure or surgery, different site or organ system, separate incision/excision, separate lesion, or separate injury (or area of injury in extensive injuries) not ordinarily encountered or performed on the same day by the same individual.nn4. Take a closer look at your billing system.nDoes your vendor incorporate National Correct Coding Initiative (NCCI) edits and update these edits quarterly? If so, are you certain that each payer has adopted those edits in its reimbursement policies? Do templates or billing automation encourage modifiers when they aren’t warranted or omit modifiers that are required?nn5. Append each modifier to the correct code.nFor example, modifier -59 should accompany a procedure or service code but not an office visit E/M code. Always refer to the NCCI procedure-to-procedure edits or specific payer bundling rules when determining what procedure or service code should include this modifier.nnExample: When reporting an excisional biopsy and lesion destruction, append modifier -59 to the code for the lesion destruction. When removing an intrauterine device and inserting a Nexplanon during an office visit, append modifier -59 to the code for the IU removal. Modifier -25, on the other hand, is always appended to an E/M office visit code when supported by the circumstances of the encounter, says Elhoms.nn6. Know what to do if you run into payment problems.nConsider the following advice:nnBalance bill the patient. While most payer contracts don’t permit this, a physician who is not under contract with a commercial payer may have the option to do so if all other state statutory advance notice requirements are met. Physicians are not permitted to balance bill patients with Medicare, and some states are enacting statutes to limit exposure of patients to either non-covered service costs or disallowed amounts for services that are covered, says Miscoe.nFight the denial. If the payer hasn’t published a policy on modifier usage, physicians may be able to successfully appeal the denial by citing standard industry guidance (e.g., CPT definitions of various modifiers, the NCCI Policy Manual for Medicare Services, or even medical policies of other major commercial payers), says Miscoe.nNegotiate your payer contracts. Ask payers to accept modifiers in all or certain circumstances, says Elhoms.nnTaking proactive steps to ensure compliant use of modifiers pays dividends in the long run, says Elhoms.nnOriginal 
This is a 46-year-old black female. She had prolapsed uterus causing her pressure, but she also had 2 previous bladder repair procedures that we removed the mesh, removed the suture, gave her proper time of healing, give her Estring cream for re-estrogenizing the vagina, and then we decided to go ahead and repair this. So, the patient was prepped and draped in the usual manner. Observing all aseptic technique, she was given a general anesthetic and prepped and draped. We put in a uterine manipulator and a Foley catheter and then we turned our attention to the above. We put in 4 port sites. These port sites were docked to an X1 robot, 1 port was for the camera, 1 port was for the PK bipolar cautery and laparoscopic scissors of the port, and then we had an assist port. The patient was docked to the patient’s side-docking in a steep Trendelenburg position. Then, we turned our attention to the console.nnAfter the patient was docked appropriately, we want on inspecting and saw a large right ovarian cyst that we thought would need to be removed. We looked at the left side. The left side was totally normal. So, we started on the left side at the round ligament. This was cauterized with the PK and then laparoscopically we cauterized and then developed an anterior and posterior aspect of the broad ligament. Then, we looked at the infundibulum and in the ovarian ligament. This was cauterized until secure, and then, laparoscopically we used scissors for cautery as well as to excise the tissue. We skeletonized and want down to the bladder flap anteriorly and went posteriorly and then we skeletonized and saw the uterine vessels they were cauterized until secure.nnThen, we turned our attention to the right side, which was a large ovarian cyst. We took the right ovary by going through the infundibulopelvic pelvic 1igament, IP. This was cauterized and cut until secure and then we went up to the broad ligament inc1uding removing the fallopian tubes and then the round ligament. We excised anteriorly again to deve1op bladder flap posterior1y just to get down to the uterine vessels that were cauterized. Then, once they were cauterized and secure next our attention to pushing the bladder well off the cervix. By using the uterine manipulator, the caudal ligaments were secure and then we circumferentially removed the cervix and then we pulled it out the cervix.nnThe uterus and the right tube and ovary through the vagina, irrigated, and then we used the V-Loc running locked stitch to secure the cuff, running it forward and backwards for good hemostasis. AlloWrap was used to put on the cuff to prevent any adhesive disease, and then we put in a pain pump, On-Q pain pump for pain. This was put in without complications. Then, as my assistant was closing the port site and undocking the robot, I turned my attention to below.nnAt this point, the patient was still in the dorsal lithotomy position, 1.5 cm from the urethral meatus, we did do a vertical incision and removed that 1 stitch that was from a previous surgery and then undermined until we got to the operative fossa. This was done bilaterally and at the level just below the pubic ramus, but also below the obturator fossa and then we used the Co1oplast TOT, and we anchored it on one side to the left side first and then we made sure the sling was lying flat and at the center of the posterior urethrovesical angle and then the second right side was placed and without complications.nnWe secured it and tied it up with tension. Then, we cut the suture and then we reapproximated the incision with 0 and 3-0 Vicryl in a running locked stitch. We took out the catheter. There was no need for cystoscopy since we did not do a TVT or TOT. The urine was clear. There was no air into the Foley catheter. We discontinued the procedure. The patient was transferred to the PACU in satisfactory condition.
Healthcare costs have been an increasingly popular conversation among doctors, patients, insurance companies and even the government. Colorado Governor, Jared Polis is getting involved and proposing the potential of reducing healthcare costs in Colorado. Read the article below from KOAA News5 of his new plan.nnDENVER – Gov. Jared Polis and Lt. Gov. Dianne Primavera announced their plan to reduce healthcare costs for Coloradans Thursday morning in Denver.nnGov. Polis laid out his “Roadmap for saving Coloradans money on healthcare” in an announcement outside Denver Health.nnThe plan featured six main points, which Polis billed as short-term solutions to reducing health care costs.n