nnSmall practices could add points to their total performance scores in the merit-based incentive payment system and may qualify for an exemption from EHR requirements.nnMore small practices may qualify for exclusions from the Quality Payment Program (QPP), claim hardship exceptions from electronic health record (EHR) requirements, and earn automatic bonus points if the proposed QPP rule released June 20 is finalized.nnThe Centers for Medicare & Medicaid Services has proposed increasing two low-volume thresholds that would grant additional exclusions in 2018:n
nnEmotional Intelligence (EI) – Many of us are familiar with IQ tests, which measure our intellectual abilities and intelligence. Many of us also believe that having a high IQ makes you the best candidate for any job. However, employers are focusing more on emotional intelligence rather than academic aptitude. Emotional intelligence is the capability of individuals to recognize their own and other people’s emotions, discern between different feelings and label them appropriately, using emotional information to guide thinking and behavior, and manage and/or adjust emotions to adapt to environments or achieve one’s goal(s). EI can be a huge asset to employers because it is the one part of the human psyche that we can develop and improve by learning and practicing new skills. We’ve all met very clever and intelligent people who nonetheless had no idea about how to deal with people, and the reverse. How we manage ourselves and the relationships we have with others can have a lasting impact on future opportunities.
Check out this article regarding the announcement that Anthem has calmed controversy over Colorado’s health insurance by submitting its proposed plan for 2018 to the state. nnHealth insurance giant Anthem announced late Monday that it has submitted proposed 2018 plans to the state, easing fears that it might back out of Colorado’s health insurance exchange and leave residents of several counties without an insurance choice.nnBut an Anthem spokesman declined to provide specifics on those plans — including where the company expects to offer them — meaning it remains unclear if Anthem will continue to provide coverage to the same number of Coloradans it currently does.nnMonday was the deadline for insurers hoping to participate next year on the Connect for Health Colorado exchange to file their proposed plans and rates with the state Division of Insurance for review. The exchange is a one-stop shop for health insurance on the individual market — where people buy their own plans, instead of receiving coverage through an employer or the government.n
nnCPT code 20680 requires the provider to incise through muscle layers and into the bone, necessitating a more complex, layered closure. The physician makes an incision overlying the site of the implant using deep dissection to visualize the implant (usually below the muscle level and within bone), using instruments to remove the implant from the bone. The physician repairs the incision in multiple layers using sutures, staples, etc. CPT Assistant and the AAOS (American Academy of Orthopedic Surgeons) direct that the 20680 code is to be billed once per fracture site, rather than based on the number of pieces of hardware removed or the number of incisions made to remove the hardware from one fracture site or original area of injury. Billing 20680 more than once is only appropriate when hardware removal is performed in a different anatomical site unrelated to the first fracture site or area of injury. It is fraudulent to send a patient to the OR/ASC for the sole purpose of seeking reimbursement for 20680, when medical necessity is not supported.
CMS proposed a final set of codes in April’s hospital IPPS rule, including over three hundred changes.nnStarting Oct. 1, it will be possible to select a specific ICD-10-CM code when a patient is in remission from abuse of each of a variety of substances, including alcohol, opioids, cannabis, and nicotine.nnThose nine new codes are among 360 new, 142 deleted, and 226 revised diagnosis codes in the final 2018 
As part of the new coding format for our newsletter, Welter Healthcare Partners is excited to offer you a new surgery coding series in which we want to help you! The 2nd week of every month we will highlight a complicated surgical case. This week we are highlighting a general surgery case. We want to hear from you! If you have a complicated surgery case and need help with coding, 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. 
nnThe Wanna Cry or Wanna Decryptor ransomware virus swept the globe last month and virtually shut down several dozen regional health authorities within the National Health Service of the United Kingdom, while simultaneously impacting the operations of such diverse entities as Spain’s national telephone service, La Telefónica; Germany’s railway system, Deutsche Bahn; automotive plants of the French car manufacturer, Renault; the Russian Interior Ministry; and universities in China and Taiwan.nnIn its notice sent out as part of Office of the National Coordinator for Health IT (ONC) and the Office for Civil Rights (OCR) list serves, HHS stated that the department is aware of two, large, multi-state hospitals systems in the U.S. that are continuing to face significant challenges to operations because of the WannaCry malware. HHS specifically notes that this not a new WannaCry attack.nnThe virus can persist even on a machine that has been patched, however, the virus will not spread to a patched machine, but the attempt to scan can disrupt Windows operating systems when it executes. The particular effect varies according to the version of Windows on the device, HHS stated.nnWannaCry ransomware is a fast-propagating worm which exploits Windows’ Server Message Block version 1 (SMBv1) protocol to move through a network or infect other systems on the Internet. However, according to HHS in its notice, SMBv1 might not be the only vector of infection for WannaCry, so even patched systems could still be infected if the malware is introduced to the system in a different manner.n
Most long-term relationships are built on mutual trust and respect. Valuable relationships are not built on mistrust, fear or intimidation. Same holds true for the relationship your practice has with payers, and especially payer representatives. A little sugar can go a long way when you need help resolving claims issues or credentialing problems. Resist the temptation to beat up on the payer reps you encounter over the phone and don’t ever write a nasty, insulting e-mail. These almost always backfire and once the bullet leaves the gun you can’t bring it back.nnBelieve it or not, you need these people and they have long memories. Having done this for almost 30 years, I have found the payer reps, like me, are not perfect but they really do want to help resolve issues not make them worse. Take the long view, create a relationship!nn
Telehealth Services: As of 2017, many payers are now legally required to reimburse providers of various specialties for telehealth services. Billing and Coding reimbursement rules for telemedicine can be extremely cumbersome. Follow these compliance tips and the financial impact for your practice can be significant:nCLICK HERE TO SUBMIT A CASE STUDY TO THE SURGERY CODING SERIES!
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Industry Hot Buttons- Medicare Advantage!
Medicare Advantage: You have probably heard some industry buzz about the recent investigations (and settlements) into risk adjustment fraud with several of the major insurers. United Health Group along with others, are accused of manipulating diagnosis codes to make patients appear to be sicker to achieve higher reimbursement outcomes via the Medicare Advantage program. Medicare Advantage allows providers to participate in a reimbursement model based on risk adjustment factor. Risk adjustment factor is determined by diagnosis complexity and specificity. Providers who treat patients that are sicker or have more chronic conditions are reimbursed at a higher rate per patient, regardless of actual health outcomes. This all relates back to the importance of understanding the False Claims Act and maintaining an ongoing internal compliance program. If you are still in the mindset of thinking accuracy with regards to reporting diagnosis codes is meaningless – Think Again!n
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- Are you currently participating in a Medicare Advantage Organization (MAO)?
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nRoutine monitoring is required to ensure risk adjustment factor is being properly determined and in alignment with provider clinical documentation! Call us for an audit today!n
CLICK HERE TO SUBMIT A CASE STUDY TO THE SURGERY CODING SERIES!
Check out this reminder from CMS about Medicare and the social security number initiative, as well as tips and links to where you can learn more about the announcement.nnAs you know, beginning in April 2018, CMS will start mailing Medicare cards with new Medicare Beneficiary Identifiers (MBIs) to all people with Medicare. The MBI will replace the Social Security Number (SSN)-based Health Insurance Claim Number for transactions like billing, eligibility status, and claim status after a 
It would be better that you know that it is a good idea.nnPutting together a well thought out and honest Proforma can prove the business case of an idea…or disprove it.nnAll revenue has an expense, all expenses should have some attributable revenue. A proforma is a list of both revenue and expenses in incredible detail and granularity. If there is a business case a thorough proforma will prove it. And…as a bonus the proforma calculations can become your budget control document to keep good ideas good.nnWe do medical management proforma’s… we we do them well! Spend a few bucks to insure that you will make a lot of bucks.nn
Welter Healthcare Partners is excited to present our helpful career advancing tips and strategies to sharpen the skills prospective employers look for in a coder!nnSoft Skills: What are they exactly? And why are they so crucial to landing your dream job? Soft skills are used synonymously with interpersonal skills and are always in high demand. These are typically skills that are more social than technical like standard job-related requirements. Soft skills include a broad range of areas – here are just a few examples: communication, executive presence, gravitas, relationship-building, decisiveness, self-motivation, leadership, team work, creativity, and resiliency. Employers desire candidates with strong soft skills as these skills are invaluable to the success of any business and are imperativento fostering a dynamic workplace.
The Republican Health Bill financial analysis will reveal whether or not the bill will miss required targets, and ultimately determine if the House will have to redo the vote.nnHouse Republicans are waiting anxiously for a new financial estimate on their Obamacare repeal proposal that could force them into a do-over on the bill they barely passed early this month.nnSpeaker Paul Ryan says he is uncertain about the nonpartisan Congressional Budget Office analysis of the measure’s budget impact — critical for meeting Senate rules that would let the GOP pass it with a simple majority amid unanimous Democratic opposition.nn”We have every reason to believe we are going to hit our mark,” Ryan of Wisconsin told reporters Tuesday. Still he added, “CBO scores have been unpredictable in cases in the past.”nnFor the health plan to comply with requirements for using a streamlined Senate process called reconciliation, the CBO will have to conclude that it reduces the deficit by at least $2 billion over 10 years. If not, the House will have to redo the bill to meet that standard and vote on it again. And that won’t be easy after the weeks of negotiations and revisions that led to the American Health Care Act’s May 4 
Welter Healthcare Partners is excited to present our monthly Code Spotlight! Each month, Welter Healthcare Partners will spotlight a unique CPT or ICD-10 code to profile and discuss practice applications of the code, as well as pertinent guideline reminders. nn99211: 99211 (Office or other outpatient visit for the evaluation and management of an established patient, that may not require the presence of a physician or other qualified health care professional. Usually, the presenting problem(s) are minimal. Typically, 5 minutes are spent performing or supervising these services.) is designated as the GO-TO Nurse/RN visit. In the majority of post-payment audits of 99211, the findings are conclusive – the code is widely misreported. The key to compliantly billing 99211 is that the documented face-to- face encounter must have an actual impact on the patient’s care. Merely doing a BP check, drawing labs, or administering an injection when the information obtained does not lead to management of a condition or illness, would not constitute a billable service. There should be clear documentation in the chart regarding patient/clinician exchanging medically significant and necessary information and there is management of the patient’s care via medical decision making (e.g. change in med regimen).
Centers for Medicare and Medicaid Services (CMS) Issues Section 1332 State Innovation Waiver ChecklistnChecklist Aims to Help Stabilize State Health Insurance Markets for 2018nnThe Centers for Medicare and Medicaid Services (CMS) released new information to help states seek waivers from requirements in the Affordable Care Act (ACA). The new tool is intended to help states complete waiver applications that allow them to establish high-risk pools/ state-operated reinsurance programs. Section 1332 waivers, generally can be used by states to opt-out of some mandated provisions under ACA.nnCMS is helping to provide guidance to states who want to pursue solutions to help lower costs and increase coverage choices for Americans struggling with unaffordable premiums and reduced competition in the insurance market, brought on by the ACA. Individuals obtaining coverage in the ACA marketplace have faced double-digit premium increases and insurance issuer exits.nnNationally, premiums on Healthcare.gov have increased by an average of 25 percent for 2017. The state of Arizona saw insurance costs go up more than 100 percent and one-third of counties in the U.S. currently only have one insurer participating in the exchange. Two insurance carriers in Iowa recently announced they were exiting the market, leaving Iowans in jeopardy of having no insurers participating in the exchange in 2018.nn“Today’s guidance addresses the ACA’s impact in driving up insurance costs and reducing choices,” said CMS Administrator Seema Verma. “State initiated waivers that implement high-risk pool/ state-operated reinsurance programs will help lower premiums, stabilize the health insurance exchange, and meet the unique needs of each state.”n
CMS published three informative resources to guide eligible clinicians participating in Merit-based Incentive Payment System (MIPS) in 2017: a fact–sheet on MIPS participation, another on MIPS data reporting for clinical improvement activities, and a list of qualified registries available for reporting MIPS data.nnWith eligible clinicians transitioning to the federal program this year, these clarifying resources will answer many lingering questions regarding MIPS reporting for the Quality Payment Program under MACRA.nnThe MIPS participation fact–sheet offers a concise overview of who is expected to participate in MIPS, what participation entails, and the guidelines for voluntary participation. Additionally, the MIPS participation fact–sheet provides information on what is expected of clinicians practicing in rural areas (RHCs) or federally qualified health centers (FQHC).nnThe fact–sheet specifies RHCs and FQHCs are not required to participate in MIPS if they are billed as such, but clinicians practicing in critical access hospitals must participate. Further, the MIPS participation fact–sheet outlines who is exempt from MIPS and all special rules for certain MIPS eligible clinicians.nnThe MIPS improvement activities fact–sheet is designed to help clinicians understand the requirements of the MIPS clinical improvement activities performance category. Given these activities are an entirely new performance category, additional information is likely welcomed by clinicians.nnThis CMS fact–sheet lists which improvement activities eligible clinicians can choose from, how to submit information for this performance category, and what the reporting criteria are for receiving credit. The fact–sheet also lays out the scoring methodology for groups including the different weights of each activity and how these weighted activities translate on the point scale.nnFinally, CMS addresses scoring for alternative payment model (APM) participants and the procedure for submitting potential future improvement activities to add to the list of existing CMS-approved improvement activities eligible clinicians can choose in the coming yearsn
The Colorado Department of Health Care Policy & Financing recognizes some providers have had difficulties submitting claims during the transition to the new claims payment system (the Colorado interChange).nnIn an effort to ensure providers are appropriately paid for services to members, they are temporarily changing the limit for timely filing.nnEffective May 12, 2017, the timely filing limit will be extended to 240 calendar days.nnTherefore, they recommend providers hold claims with a DOS after December 1, 2016 (that are outside the 120 days timely filing limit) and do not submit those claims until after May 12, 2017. The system will automatically calculate the additional time and providers do not need to take action to receive the extension during claims submission.nnEffective November 1, 2017, the limit will be changed back to 120 calendar days.nnOn November 1, 2017, all claims with a DOS prior to July 4, 2017 will be outside the timely filing limit of 120 days, and providers will need to submit additional documentation to request a timely filing extension.nnExamples:n
Week 1 – Industry Hot Buttons!nnModifier 25: Modifier 25 landed itself on both private payer and the OIG hit lists again this year for overuse and blatant misuse leading to millions in overpayments – and everyone wants their money back! Applying Modifier 25 incorrectly can cost your practice tens of thousands of dollars! Understanding this modifier’s appropriate application can be very tricky.nnHere are a few questions to consider before sticking that modifier on your next claim:n