Mar 22, 2021 | Uncategorized
The webinar training has been announced for the 2021 E/M technical corrections! Join Welter Healthcare Partners in a webinar training event to go over the newest changes in E/M guidelines and stay up to date on the newest coding changes. Check below for times and dates for the upcoming webinar training and register your practice/organization! nnBy Ginger Avery, CPC, CPMA, CRC nMarch 17, 2021nnSince the release of the January 1, 2021 updated E/M guidelines for office or other outpatient (CPT codes 99202-99215) and prolonged services (CPT codes 99354, 99355, 99356, 99417), the AMA has received an abundance of feedback from clinicians on areas of confusion. The AMA’s CPT Editorial Panel has made several technical corrections to add clarity to these exciting updates. These technical corrections were released March 9th and are effective January 1, 2021.nnThe summary of updates listed below reveals that most of the new information is concentrated on medical decision making (MDM) definitions:nn
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- Total Encounter Time Reporting: Clarification has been made when to NOT count time.
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- Five new MDM definitions added:n
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- Analyzed – referred to in the data element of Table 2 of the guidelines
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- Combination of data elements
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- Discussion
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- Unique Test and Unique Source
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- Surgery: minor vs. major
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- Revised Definitions have been created to clarify the following terms:n
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- Drug therapy requiring intensive monitoring for toxicity
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- Independent Historian
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- Risk
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- Test
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- Clarification provided for separately reported tests and interpretation.
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nMake sure your organization is up-to-date with these recent revisions and has a solid understanding of the new 2021 E/M Guidelines for office visit services. These monumental changes cannot go unnoticed! Register below for a one-hour webinar presented by Welter Healthcare Partners on these crucial updates. If you have any submission issues with the contact form, please email Cody at cwhitworth@rtwelter.com to register. nnAll webinar registrants will receive 5 of Welter Healthcare Partners’s 2021 Office Visit E/M Coding Tools!nn[dt_divider style=”thin” /]nn[gravityform id=”18″ title=”false” description=”false”]nnThese unpredictable updates to our ever-changing healthcare environment should serve as a reminder to visit AMA’s Errata & Technical Corrections regularly for any noted changes. nn
Mar 18, 2021 | Uncategorized
Several technical corrections have been made in the recently released 2021 E/M guidelines. With feedback from clinicians to clarify these new guidelines, new summary updates have been presented to clear up any confusion. Stay updated with the clarified E/M guidelines today. Continue reading below to learn more.nnBy Ginger Avery, CPC, CPMA, CRCnMarch 17, 2021nnSince the release of the January 1, 2021, updated E/M guidelines for office or other outpatient (CPT codes 99202-99215) and prolonged services (CPT codes 99354, 99355, 99356, 99417), the AMA has received an abundance of feedback from clinicians on areas of confusion. The AMA’s CPT Editorial Panel has made several technical corrections to add clarity to these exciting updates. These technical corrections were released March 9th and are effective January 1, 2021.nnThe summary of updates listed below reveals that most of the new information is concentrated on medical decision making (MDM) definitions:n
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- Total Encounter Time Reporting: Clarification has been made when to NOT count time.
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- Five new MDM definitions added:n
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- Analyzed – referred to in the data element of Table 2 of the guidelines
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- Combination of data elements
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- Discussion
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- Unique Test and Unique Source
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- Surgery: minor vs. major
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- Revised Definitions have been created to clarify the following terms:n
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- Drug therapy requiring intensive monitoring for toxicity
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- Independent Historian
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- Risk
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- Test
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- Clarification provided for separately reported tests and interpretation.
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nMake sure your organization is up-to-date with these recent revisions and has a solid understanding of the new 2021 E/M Guidelines for office visit services. These monumental changes cannot go unnoticed! Register below for a one-hour webinar presented by Welter Healthcare Partners on these crucial updates. If you have any submission issues with the contact form, please email Cody at cwhitworth@rtwelter.com to register. nnAll webinar registrants will receive 5 of Welter Healthcare Partners’s 2021 Office Visit E/M Coding Tools!nn[dt_divider style=”thin” /]nn[gravityform id=”18″ title=”false” description=”false”]nnThese unpredictable updates to our ever-changing healthcare environment should serve as a reminder to visit AMA’s Errata & Technical Corrections regularly for any noted changes. nn
Mar 18, 2021 | Uncategorized
Bartholin’s Gland Cysts treatment can come in many different forms. With treatment comes coding for the different classifications and procedures to take care of the cysts. Staying up-to-date with coding can help you organize and get ready for treatment. Continue reading below to learn more!nnBartholin’s glands are two fluid-filled swellings that lubricate the vagina prior to and during sexual intimacy. Due to their size, they can easily become blocked or obstructed by bacteria and cause a cyst or abscess Most Bartholin’s cyst are asymptomatic and resolve on their own. If ancyst does not resolve on its own, it can grow larger, swollen, and painful. nnTreatment options:nnSitz baths and time are usually the first line of treatment. In most instances, the cyst will rupture on it’s own. However, if conservative treatment does not work, an incision and drainage may be done with a word catheter inserted into the cyst space. This word catheter is left in place from four to six weeks to help with healing. Another treatment is surgical marsupialization. The physician will grasp the cyst and create a vertical incision between 1.5 and 3.0 cm long. This will drain the gland cavity. After that the cyst will be open and the physician will suture the edges of the sit to form a continuous surface from the exterior surface to the interior surface of the cyst. Clinicians also use lasers and injections to treat these cysts. It is also possible to surgically excise the gland or cyst from the vaginal area. Excision of the cyst is the most invasive treatment option. nnCPT CODING: n
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- 56420: I&D of Bartholin’s gland abscess
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- 56440: Marsupialization of Bartholin’s gland cyst
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- 56740: Excision of Bartholin’s gland cyst.
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nCPT code 56420 is used to report an I&D for a gland that is abscessed. If there was no abscess present, (the cyst was filled with clear fluid), and an I&D was performed, the coder should report one of the following:n
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- 10040: Acne surgery (ie: marsupialization, opening or removal of multiple milia, comedones, cysts, pustules)
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- 10060: I&D of abscess (ie: carbuncle, suppurative hidradenitis, cutaneous or subcutaneous abscess, cyst, furuncle, or paronychia), simple or single
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- 10061: … complicated or multiple
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nCode 56740 is used to report a complete excision. If the clinician uses a C02 laser or performs a destruction, then report CPT code 56501 (destruction of lesion(s), vulva, simple) or 56515 (…extensive)nnICD 10 CM Coding:n
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- N75.0: cyst of Bartholin’s gland
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- N75.1: abscess of Bartholin’s gland
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- N75.8: Other diseases of Bartholin’s gland
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- N75.9: disease of Bartholin’s gland, unspecified.
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nBe sure to code either a cyst or an abscess. If the clinician notes the presence of bacteria within the abscess, a laboratory code for the specific bacteria can be coded secondary to the abscess code. nn** AMA CPT 2021nn** AMA ICD-10-CM 2021nn** AMA Obstetrics and Gynecology
Mar 11, 2021 | Uncategorized
President Biden plans to address the mental health and addiction crisis after both have worsened since the start of the pandemic. He plans to split the funding for this endeavor between substance abuse and mental health services. Continue reading below to learn more.nnPresident Biden is directing $2.5 billion in funding to address the nation’s worsening mental illness and addiction crisis, an official from the U.S. Department of Health and Human Services tells Axios.nnWhy it matters: Confronting the mounting mental health and substance abuse crisis will be imperative for the Biden administration, even as its primary focus is on combating the broader COVID-19 pandemic.n
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- The funding announced today is designed to increase access to services for individual Americans.
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- The funding surge comes as the president has yet to fill several key permanent positions in agencies that would lead the charge in combating the drug epidemic, including the Food and Drug Administration and the White House Office of National Drug Control Policy.
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- His pick to lead HHS, Xavier Becerra, is expected to be confirmed by a close vote.
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nBetween the lines: The funds will be broken down into two components by the Substance Abuse and Mental Health Services Administration.n
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- $1.65 billion will go toward the Substance Abuse Prevention and Treatment Block Grant, which gives the receiving states and territories money to improve already-existing treatment infrastructure and create or better prevention and treatment programs.
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- $825 million will be allocated through a Community Mental Health Services Block Grant program, which will be used by the states to deal specifically with mental health treatment services.
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nBy the numbers: A survey conducted last year and published in August 2020 by Centers for Disease Control and Prevention showed that 41% of U.S. adults reported struggling with mental health or substance abuse related to the pandemic or its solutions, like social distancing.n
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- Before the pandemic, over 118,000 people died by suicide and overdose in 2019. An HHS official says the administration is expecting that number to increase because of the COVID-19 pandemic.
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- Preliminary data out of the CDC indicates that the number of drug overdoses through July 2020 increased by 24% from the year prior.
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nFlashback: On the campaign trail, then-candidate Biden often spoke about the need to address the mounting mental health and substance abuse crisis in America, an issue that hits close to home. His son, Hunter, has openly discussed his own struggles with addiction.nnThe National Suicide Prevention Lifeline (1-800-273-8255) provides 24/7, free and confidential support for anyone in distress, in addition to prevention and crisis resources. Also available for online chat.nnOriginal article posted on axios.com
Mar 11, 2021 | Uncategorized
This month’s operation report features Spinal Adhesion Barriers. The practice of using spinal adhesions within laminectomies is nothing new and this is considered a standard of practice that is essential for good patient recovery. When performing these operations, there are additional questions to be asked about the coding and billing involved. Continue reading below to learn more!nnDo 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. n
– Click Here to Submit Redacted Surgery Case Study –
nQuestions to Consider:n
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- How is your spinal practice coding/billing for this additional work?
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- HCPCS code C1765 is used to bill for the device but how are your surgeons being reimbursed?
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n nnDATE OF SURGERY: 12/XX/2020nnSURGEON: D., MDnnASSISTANT SURGEON: M., SA-CnnPREOPERATIVE DIAGNOSIS: Degenerative lumbosacral spine (LS through S1).nnPOSTOPERATIVE DIAGNOSIS: Degenerative lumbosacral spine (LS through S1).nnOPERATIONS: Anterior exposure for lumbosacral spine fusion (L5-S1). Intraoperative fluoroscopy. Vessel Guard patch. Abdominal x-ray reading.nnSPINE SURGEON: Dr. G. G.nnANESTHESIA: General endotracheal.nnESTIMATED BLOOD LOSS: MinimalnnINDICATION FOR SURGERY: This is a 49-year-old male with degenerative lumbosacral spine, who needs anterior exposure £or fusion at the level of the disk LS-Sl.nn nnDESCRIPTION OF PROCEDURE:nnThe patient was brought into the operating room and placed on the table in supine position. After general anesthesia was administered, the intraoperative fluoroscopy was used to identify the level of the disk L5-S1 and the projection of the disk at the level of the anterior abdominal wall was marked with a transversal line in the suprapubic area. The abdomen was prepped and draped in the usual sterile fashion. nnA small transversal incision was done in the suprapubic area on top of the previously placed line and the incision was deepened through the subcutaneous tissue and through the fascia. The fascia flaps were elevated, and at the level of the midline between the rectus muscles, the peritoneal sac was approached and gently dissected and pushed to the left side. It was a little bit more difficult to enter the right retroperitoneal space and below the arcuate line, but it was possible to enter without any complications. The right retroperitoneal space was entered, and the peritoneal sac was further mobilized together. The ureter was pushed to the left side. The ureter was protected and visualized at all time. The vascular dissection was started between the iliac vessels using only gentle blunt dissection to avoid, injuries to the superior hypogastric plexus in this young man. Few presacral veins were identified and divided using bipolar electrocautery and middle sacral artery which was well represented partially imbedded in the soft tissue in front of the spine was divided using bipolar electrocautery, obtaining a good hemostasis. The vascular dissection was further continued using blunt dissection until both iliac vessels were mobilized, completed the right and left side of the spine obtaining a complete clearance of the entire disk space LS-S1. A needle was inserted in the disk exposed, and using intraoperative fluoroscopy, the level of the spine exposure was demonstrated. nnThe SynFrame was placed maintaining the exposure at the level of the disk LS-S1. At this point, Dr. G. came into the operating room and the case was turned to Dr. G. for the orthopedic part of the spinal fusion. After his part of surgery was completed, I came back to the operating room and I took over the case again. very good hemostasis was noted. No injury was seen. At this point, a Vessel Guard patch measuring 5 x 7.5 cm was chosen, was tailored to match the shape of the vertebral space exposed and secured in place with 2 stitches for 4-0 PDS suturing the upper part of the patch to the anterior longitudinal ligament of the vertebral body LS. The patch was able to cover completely the entire anterior aspect of the spine exposed and the hardware used for the fusion. The retractor blades were very carefully gently removed allowing the iliac vessels and the peritoneal sac to come back in a normal anatomical position on top of the patch. At the end of the procedure, very good hemostasis was noticed, very good flow through the iliac vessels. No ureteral injuries and no lymphatic leak. nnThe abdomen was closed in a standard fashion using a stitch with O Vicryl to approximate the rectus muscle below the midline and then the anterior fascia layer was closed with continuous running O loop PDS. The subcutaneous tissue was irrigated. Local anesthesia was injected. At this point, the intraoperative fluoroscopy was used to x-ray the abdomen for the instrument count and no instruments were found in the surgical field. The subcutaneous tissue was closed with continuous running 2-0 Vicryl, and the skin was closed with continuous running 3-0 Monocryl subcuticular closure. Steri-strips and sterile dressing were applied. nnThe patient tolerated the procedure well. At this point, the patient was kept under general anesthesia and turned back to Dr. G. and anesthesiologist for the posterior part of the spinal fusion.
Mar 4, 2021 | Uncategorized
The pandemic increased the number of patients facilities are seeing and this also lead to the increase in the use of self-pay accounts. Your facility may not have been prepared for this sudden increase. Continue reading below to learn some key strategies to better manage your self-pay accounts.nnA study published late last year by the Urban Institute forecasted that over 10 million families would lose their employer-sponsored health insurance during the novel coronavirus (COVID-19) pandemic. As a result, healthcare organizations have observed a growing number of uninsured patients and a rise in out-of-pocket responsibility.nnOn the latest episode of The Revenue Integrity Show: A NAHRI Podcast, NAHRI Director Jaclyn Fitzgerald, CHRI, was joined by Juli Forde, director of strategic partnerships, AR optimization, ZOLL Data Systems in Broomfield, Colorado, for a wide-ranging discussion on how healthcare organizations should approach the new reality of escalating self-pay patient responsibility.nnForde offered several strategies to help organizations maximize reimbursement in these times. The first step, she said, is to ensure empathy and understanding toward the patient. “I think one of the things we do really well is we get a great H&P (history and physical examination) clinically for patients before we move into a treatment plan,” Forde said. “We make sure we really understand them. We need to be doing the same thing financially. So, a wonderful best practice is to obtain one of the solutions available that will partner with you and give you the financial information around the patient. That allows you to come alongside them in a way where they feel heard and they feel understood.”nnOrganizations can obtain a financial profile of an individual without asking invasive questions that make the patient uncomfortable, Forde said. One of the keys is for organizations to harness the new technologies that are available that help organizations understand the patient as a financial individual in addition to knowing them clinically.nn“If you’re still doing revenue cycle the way you did it five years ago, 10 years ago, there’s wonderful technology that you’re missing out on that really helps you deal with this profoundly difficult reality of a greater patient responsibility, a higher denial rate from the payers, an additional regulatory burden being placed on healthcare,” Forde said. “There are tools available that really make those lifts a lot easier and help you to maximize your reimbursement while giving the patients a wonderful experience.”nnIn addition, Forde stressed the importance of charity care. She said healthcare providers must put in place policies based on objective criteria to establish a successful charity care program, which should benefit both the patient and the organization. When organizations ask patients for the amount that they can truly afford based on their own financial characteristics, they see the average patient collection increase significantly, according to Forde. “So it’s very interesting that by appropriately and compassionately discounting the final charge within a compliant charitable discounting program, we actually recoup more of the patient’s self-pay responsibility,” she said.nnTo listen to the full podcast episode, search Revenue Integrity Show on iTunes, SoundCloud, Spotify, or Google Play. The episode is also available to stream on the NAHRI website.nnOriginal article published on nahri.org
Mar 4, 2021 | Uncategorized
The current Public Health Emergency has changed the way CMS has implemented new programs, such as MIPS and APM, and the timeline in which they will be incorporated. As MIPS & APMs continue to move forward, it is important to stay up-to-date about the newest changes in CMS policy and the way these new programs are being introduced. Continue reading below to find out more! nnAmong so many other timelines that were interrupted during our current Public Health Emergency (PHE), Medicare Access and CHIP Reauthorization Act of 2015 (MACRA), also was thrown in a tailspin. Despite the challenges that have presented over the past year, the business of medicine must continue moving forward.nnDuring the PHE, the Centers for Medicare and Medicaid Services (CMS) has delayed the implementation of MIPS Value Pathways (MVPs) until no earlier than 2022. However, the Merit-Based Incentive Payment System (MIPS) and Advanced Alternative Payment Models (APM) have been finalized for performance year 2021.nnThese elements of the Quality Payment Program (QPP) have also had some added flexibility by CMS during the PHE to encourage greater participation to Medicare Part B providers while removing some of the risk of a negative payment adjustment. As we begin the last month of the first quarter in 2021, it is important to mark March 31st on your calendar as this is the first of three APM participation snapshot dates for 2021. This is then followed by the April 1st opening of registration for the Consumer Assessment of Healthcare Providers and Systems (CAHPS) surveys as part of your MIPS participation.nnThis is not the year to sit back when it comes to your QPP participation. According to MACRA, CMS is required to have the QPP program fully incorporated by 2022.nn n
Click here to learn more on cms.gov
Feb 25, 2021 | Uncategorized
There are 5 emerging trends in value-based care for 2021. The practice of value-based care has picked up momentum because of the pandemic and pressure has been put on healthcare providers to stay up-to-date with trends. Continue reading below to learn more about the 5 emerging trends in value-based care this year.nnThe pace and pressure to embrace value-based care are picking up. The COVID-19 pandemic exposed the risks and limitations of reliance on fee-for-service reimbursement and, combined with the groundbreaking changes in health care delivery models and regulatory flexibility, indicate a renewed focus on value-based care. This article outlines five of the top trends to watch for in value-based care for 2021.nn1. Leaning Into Value-Based CarenOne of the lessons from 2020 is that reliance on fee-for-service can leave providers vulnerable to volatility and changes in demand. As utilization plummeted during the COVID-19 pandemic, providers who had invested heavily in value-based care have been better able to weather the pandemic and the economic downturn by having a consistent source of revenue despite low utilization. The rapid changes in health care driven by the pandemic only further emphasized the need for providers to lean into value-based care. Beyond the allure of steady revenue streams, new regulatory flexibilities and care delivery innovation creates an opportunity for providers to realize a more rapid rate of return on their investment in value-based care by increasing the portion of their business with value-based care reimbursement.nn2. Continued Innovation and DisruptionnWhile value-based care has always been an area ripe for innovation, 2021 presents a unique set of circumstances that point to a surge of innovation and disruption in both payment and care delivery models. Value-based care had been a priority for the Centers for Medicare and Medicaid Services (“CMS”) under the Trump administration, but there is no reason to expect a change of course away from value-based care. In fact, the Biden administration’s health care goals will likely require an increased emphasis on cost savings, which may result in an even greater push towards value-based care. Some news outlets are reporting that Elizabeth Fowler is a front-runner to lead the Center for Medicare and Medicaid Innovation, further signaling that CMS’s momentum on value-based care will continue. Commercial payors also continue to push towards innovative payment and care models as COVID-19 has highlighted the inequities in the healthcare delivery system and challenges for providers.nn3. Capitalizing on COVID-19 InfrastructurenThe COVID-19 pandemic prompted transformational changes to the health care system that portend continued opportunities to manage patient care and provide quality care in lower cost settings. As a result of the pandemic, both the federal and state governments threw open the doors to allow providers to furnish services via telemedicine and other digital health modalities during the COVID-19 public health emergency. Many of the telehealth waivers have been made permanent. Providers who have embraced digital health as a way to weather the pandemic will also have the opportunity to capitalize on this investment as a way to manage patient care and see a return on investment for services that are typically not reimbursable under fee-for-service arrangements. CMS also created the Hospital Without Walls and Acute Hospital Care at Home programs to increase hospital capacity during the pandemic. Commercial payors have been eager to seize on these opportunities to promote lower-cost services. Providers who have invested in these types of programs similarly provide an opportunity to provide quality care in lower cost environments, which will benefit providers who are fully engaged in value-based care.nn4. New Opportunities for Provider AlignmentnRecent changes to federal law aim to lower barriers to value-based care. In particular, CMS and the Office of Inspector General (“OIG”) created new flexibility under the Stark law and Anti-kickback Statute for value-based arrangements to allow providers to enter into value-based care arrangements that previously may have been prohibited. While the new exceptions and safe harbors still require that arrangements be carefully crafted, they provide new opportunities to align with providers and to incentivize activities that promote value-based goals that were previously unavailable. Additionally, the sweeping interoperability and information blocking rules aim to ensure that patients and providers are able to access health information, further reducing structural barriers to value-based care.nn5. Emphasis on Social Determinants of HealthnFinally, players in the value-based care space—particularly in Medicaid managed care programs—are placing greater emphasis on addressing social determinants of health. Providers and payors are beginning to recognize the crucial role that non-medical factors play in patient health. By solving for these issues—such as transportation, food, housing, language services, etc.—providers and payors are able to realize significant benefits in improving patient health and outcomes while keeping medical costs relatively low. The focus on social determinants of health is an emerging trend in value-based care that is likely to grow as players seek creative ways to manage patient care through value-based arrangements.nnAs providers and payors emerge from the upheaval of the pandemic and the resulting revolutionary changes in health care, we can expect renewed interest in value-based care. Opportunities abound to capitalize on the changes wrought by the pandemic, as well as emerging prospects, by fully investing in value-based care.nnOriginal article published on natlawreview.com
Feb 25, 2021 | Uncategorized
Making the most out of the time we have at work to stay healthy can be a real struggle. Health and workplace environments can alter the way we feel so finding this balance is essential to feeling your best. Continue reading to learn more about workplace health and how to stay active.nnHeart health is essential and should be part of your daily routine both at home and at work. As part of Heart Health Month, this little reminder from the American Heart Association can be printed or saved as your reminder to not let your workload distract you from a healthy life.nnFollow these five exercises as a way to break up your day.nn
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- Start with your commute; try walking or cycling to work. Even if this isn’t possible park further from the entrance or in our current COVID PHE, start with a working walk around the yard or neighborhood. Even a 5-minute walk to the mailbox can be beneficial.
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- Stretch it out; Start at your neck and move throughout your body, taking a few moments to concentrate on each area. YouTube can be a great resource to follow simple full-body stretching routines that can be done in 15 minutes or less.
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- Transform screen time; Use a standing desk or even under desk bike pedals to allow productivity to continue while moving. Even the use of stability ball chairs can help to strengthen and tone core muscles.
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- Walk and talk; the use of headsets and cellphones can allow those lengthy phone meetings to be a great opportunity for movement. You can even do this without braving the cold winter weather by using the stairs or hallways in your buildings.
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- Deskercise; Use your desk, chair, and walls to practice modified exercises. Those heavy codebooks can even be used as weights.
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Click here to learn more about health in the workplace!
nOriginal article published on heart.orgnn nn
Feb 19, 2021 | Uncategorized
MGMA CFO analyzes the financial impact of COVID-19 on physician practices and outlines some long-term strategies that healthcare organizations should implement as a precaution in case another pandemic occurs. These strategies may help avoid the negative financial impact we saw with COVID-19. Continue reading below to learn more!nnThe path forward to a more financially sustainable operation and prosperous future remains tenuous for most medical groups but there are opportunities for leaders who are willing to make the necessary changes.nnWhile hospitals and health systems suffered historic financial challenges related to the COVID-19 pandemic in 2020, medical groups and physician practices were not spared either. These smaller provider organizations endured similar constraints due to declining revenues and rising expenses, a trend that hasn’t ceased thus far in 2021.nnThe path forward to a more financially sustainable operation and prosperous future remains tenuous for most medical groups but there are opportunities for leaders who are willing to make the necessary changes. Akash Madiah, CFO of MGMA, outlines the long-term strategies that medical group executives should follow to be more resilient and less vulnerable if another pandemic or industry-changing calamity occurs.nnThis transcript has been edited for clarity and brevity.nnHealthLeaders: What is your advice for financial executives at provider organizations as they continue to deal with the difficult dynamics caused by COVID-19? Are you optimistic or pessimistic about their prospects? Why or why not?nnMadiah: First, I’d advise that everyone take advantage of the federal financial assistance programs, namely the [CARES Act] Provider Relief Fund, which has now been reopened, and the Paycheck Protection Program. Our government affairs team based in [Washington, D.C.] has done remarkable work advocating for [physician] practices and organizations to receive relief through the pandemic. MGMA members have been involved and active in the advocacy efforts. In one of our grassroots campaigns, we mobilized 2,000 medical practices to send over 7,000 letters to Congress in less than 48 hours and it helped secure sufficient funding for medical practices.nnIn the relief packages, there’s over $175 billion allocated for healthcare providers, so there is available money out there. These programs were put in place to help medical practices and businesses stay afloat and overcome the downside impact of the pandemic. With respect to these programs, they’re loans but there’s an administrative aspect to these. I think with calendar year 2021, there’s going to be a lot of backend work for the medical group community to make sure that the loans and grants are forgiven. That’s the burden for the healthcare community at large, but overall, I’m pretty optimistic about where things are going.nnThe spring and summer of 2020 were the worst of times and the darkest period. We’ve had an uptick since as people feel more comfortable going back to doctor’s offices. [With] people who skipped out on their annual checkups, those dollars aren’t ever coming back, but that’s where those relief programs were meant to help. There is a backlog of elective procedures; I think the trend is going up, and I feel that’s going to continue through the rest of the year, especially with the vaccine rollout.nnHL: What role should the federal or state governments play in assisting these care providers that are facing a dual-threat to their bottom line? Additionally, is there any action that the payer community should take to help their struggling counterparts on the provider side?nnMadiah: As I mentioned, the money is out there, so it’s up to providers to access that. I think the government has responded and everybody should be accessing the dollars based on their eligibility. But now going forward, I think the biggest thing government can do is ease the administrative burden to make sure that reconciliation and forgiveness of loans is easy for the medical groups.nnNeedless to say, medical groups are going to be busy enough this year, and focusing on patient care should be paramount and not bogged down by the administrative burden. I’ll also add that our CEO Dr. Halee Fischer-Wright sent a letter to the Biden administration [earlier this month] asking that medical group practices are included in the vaccine distribution strategy given their role as community providers across the country.nnThe payers are a little trickier, they are under no obligation to help, but I would say any cooperation and long-term view can help since we’re all in this together. [Payers] have a role in supporting the mechanisms that keep both patients and medical practices healthy in 2021, specifically making sure things that helped providers through the pandemic, like reimbursements for expanded telehealth services, continue. Then, like the government, any reduction to the administrative burden, such as relaxed prior authorization, can only help going forward.nnHL: Are you fearful about the continued effort by private equity firms to acquire medical groups or physician practices? What impact do you think that behavior will have on the healthcare industry at large?nnMadiah: When private equity enters an industry, there’s a general sense that they will cut costs, slash-and-burn, and then sell it for a profit. I think that’s probably the most pessimistic view of them. I’m not fearful of them; they’re a player in all industries across America and they can cut costs in a good way and try to create synergies to make sure revenues are increasing. When it comes to healthcare, there’s a fear [that private equity] is going to hurt the patient and decrease access to healthcare. The profit tone that comes along with private equity often takes away from the altruistic tone that we convey with our members at MGMA. That’s the push and pull with private equity.nnThe big question is how will [private equity] generate the returns they’re used to seeing while also improving the patient experience, which again means more access and better outcomes. If they’re willing to invest in technology and processes that can help the industry, there can be an upside. But that comes at a time horizon that’s a little bit longer than they’re typically used to because while healthcare is continually changing, the speed of that change is not always conducive to what private equity is traditionally invested in. With our members there’s general skepticism with what approach [private equity] is going to take; are they going to be investing for the long-haul or are they taking the short-term view and motivated by profits?nnHL: What are the critical long-term strategies that medical group executives should follow to be more resilient and avoid being vulnerable if another pandemic or industry-changing calamity occurs?nnMadiah: The biggest thing is always to be vigilant. On the expense side, make sure there’s no extra waste in your practice and [don’t] worry about cutting things when the money is tight. The other part of that is being on the offensive, to the extent you have the resources to do so. Invest in your organization to make it more efficient or profitable now rather than being reactive in an urgent situation in the future.nnOne example from the pandemic is telehealth. That was a huge lifeline to a lot of practices to make sure revenue was still streaming in, but many practices had not implemented telehealth prior to COVID-19 and they were being more reactive. We’re trying to invest more in data now to make sure we’re looking ahead and being prepared for the future.nn[Referencing] the MGMA year-in-review report, a lot of practices are changing the way they measure their key metrics of success and looking at things on a more frequent basis rather than a monthly basis.nnThis doesn’t just go for healthcare, but reassess space needs. Understand how successful you are as a remote organization and what you should be investing in going forward. That applies to a number of industries across America, but the bottom line is to be proactive, try to foresee what challenges you need to get ahead of, and make sure to invest in those areas to the extent that you can.nnEditor’s note: This conversation is a transcript from an episode of the HealthLeaders Finance Podcast. Audio of the interview can be found here.nnOriginal and complete article published on healthleadersmedia.com
Feb 19, 2021 | Uncategorized
nnCardiovascular coding continues to change and there have been some significant changes so far in 2021. With new shunting codes and add-on codes, it’s important to stay up-to-date with the latest changes. Continue reading below to learn more about the cardiovascular coding changes for 2021.nnWe have all been so focused on the changes in the Evaluation and Management section of the CPT manual that we wanted to spotlight a different code set that also received significant guideline changes in 2021, cardiac shunt procedures.nnIn addition to completely re-written guidelines, we also have three new shunting procedure codes, 33741, 33745, and add-on code 33746. Careful review and notation of all the changes is recommended, you can find the changes starting on page 262 of your CPT manual.
Feb 11, 2021 | Uncategorized
The 2021 E/M updates and elements of MDM are continually being clarified. The article below will address questions and answers over the new E/M Office visit guidelines. Read below to see more about the new updates and information. nnBy Ginger Avery, CPC, CPMA, CRC nFebruary 2, 2021nnQuestions and answers continue to be clarified as we are now a month into utilizing the new E/M Office Visit guidelines that took effect on January 1, 2021. Understanding how to navigate labs and other test results as they pertain to the time and medical decision-making (MDM) elements of the revamped E/M office visit rules can be hard to ascertain. The following details should help improve understanding of the new data review rules. nnData Element:nn
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- When tests are ordered during one visit and reviewed the same test during the next visit, can that count as a data point for both visits?n No. When a clinician orders a test during an E/M visit, the order and review of the test result will count toward the MDM of the first encounter.
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- If we receive a test result two days after the visit, can we count a data point toward that E/M visit for review of the test?n Yes, there’s pre-service work and post-service work associated with the encounter and receiving a test result a couple of days later and responding to it are part of the post-service work of the encounter.
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- Can the independent visualization of a test be counted in the medical decision making if the physician is also billing for the test?nPer AMA, the actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the level of E/M service when reported separately. Clinician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The clinician’s interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to manage the patient as part of the E/M service but is not separately reported; it is part of medical decision making.
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- If one doctor orders a test that is performed in the practice, but a second doctor bills for the test, can the first doctor count the test order toward MDM for his visit?nPractices should not count a test toward MDM if the ordering practitioner’s practice also performed and billed for the test. Medicare and private payers could view that type of coding as abusive or fraudulent.
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nDocumentation Questions:nn
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- Since history and physical exam are no longer required to level the visit, should these elements still be documented?nYes, history and exam are still part of an evaluation. The documented content should be focused only on the clinically relevant details and cognitive thoughts of the clinician. Document the nature of the presenting illness(es) (subject details with pertinent ROS). Document a medically necessary exam. Documentation is about the quality of the story, not the quantity of details. Avoid importing pages of past medical history, ROS or medication lists that are note relevant or helpful. Clinicians are encouraged to write clear stories that they would like to read.
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- Do I still have to document ROS and PFSH?nYes, when clinically relevant. For example: Patient presents with chest pain. Has been having intermittent chest pain at rest for two weeks. No notable triggers. Positive for headaches and dizziness, no SOB. Patient has a family history of CAD. Remember, documentation is all about the medically necessary story.
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- When coding based on total time does the assessment and plan still need to be documented?nYes. Quality documentation should always be captured. Clear stories that include clinical impressions and plans support the medical necessity and describe the complexity for the services provided, regardless of how you choose to report the visit.
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nOther Common Questions:nn
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- Are commercial plans required to adopt the revisions to E/M codes?nYes. The CPT code set, together with the U.S. Department of Health and Human Services’ Healthcare Common Procedure Coding System, has been adopted as the nation’s standard medical data code set. HIPAA requires that health plans use the most recent version of the medical data code set, they should have implemented these revisions Jan. 1, 2021.n
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- Do the 2021 E/M code and guideline changes apply to all categories of E/M services?nNo. The E/M code and guideline changes are specific for office and other outpatient visits and apply only to codes 99201–99205 and 99211–99215. Inpatient services still need to follow the key component guidelines (1995 or 1997).n
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- When considering High-Risk MDM, there is an example listed: “drug therapy requiring intensive monitoring for toxicity”. What constitutes supporting this definition? When considering this complexity, both the drug and the monitoring must qualify. The new guidelines provide this definition when considering this High-Risk example:n“Drug therapy requiring intensive monitoring (today) for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Both the drug and the monitoring must qualify on the date of the encounter.n
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- Where can the CPT E/M code and guidelines be found?nThe CPT E/M code and guideline changes for 2021 can not only be found on the American Medical Associations’ (AMA) site at this link. They can also be found in their entirety within the 2021 CPT Code books themselves. These guidelines include details about reporting based on the total encounter time, the new level of medical decision-making table and the 22 new definitions that help clarify what the MDM terms mean.
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nAs a reminder, documentation is about painting a clear picture of each encounter. The power of storytelling is evident with these new updates. Quality documentation provides details to support and defend the medical necessity and appropriate complexity of each unique encounter, as well as improves overall patient care and clinical outcomes. Due to President Biden recently issuing several health care executive orders, we can expect policy adjustments that will lead federal auditors and investigators to focus on subjects like: fraud and abuse (especially in the telehealth arena), auditing of provider relief funds received during the PHE, HIPPA compliance, meaningful use, workplace safety and Evaluation and Management (EM) services. With increased emphasis on these interrelated topics, clinicians are encouraged to focus documentation efforts on the cognitive clinically relevant details, regardless of the clinical setting. Document what you do, code what you document. Consider an educational audit review for your clinicians to see if they are taking proper credit for all the work they do by telling great stories in their encounter notes.nnKeep an eye out for more guidance from Medicare and private payers. Currently, Medicare is still working on an update to its documentation guidelines for E/M services. Welter Healthcare Partners provides robust coding and documentation training for these updates, as well as other topics. Please contact cwhitworth@rtwelter.com to book your training now.nnReferences:nAMA CPT® E/M Code and Guideline Changes for 2021nAma-assn.orgnNovitas E/M Documentation RequirementsnNoridian E/M Documentation RequirementsnDecision Health PartBNews
Feb 11, 2021 | Uncategorized
The report below describes a patient undergoing excision of the left dorsalis pedis artery aneurysm. The entire procedure has been documented in detail, describing the step by step process used by doctors to carry out the surgery. Keep reading for more on how this procedure was performed and to learn about the use of the unlisted procedure code for this cardiovascular procedure.nnDo 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. n
– Click Here to Submit Redacted Surgery Case Study –
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nn37799: EXCISION DORSALIS PEDIS ARTERY ANEURYSM [COMPARE TO CODE 35152 FOR UNLISTED PROCEDURE] I72.4nn
nDATE OF OPERATION: 01/XX/2021nOPERATING SURGEON: S. G., M.D.nPREOPERATIVE DIAGNOSIS: Left dorsalis pedis artery aneurysm.nPOSTOPERATIVE DIAGNOSIS: Left dorsalis pedis artery aneurysm.nPROCEDURE PERFORMED: Excision of left DP artery aneurysm.nANESTHESIA: Monitored anesthesia care with local anesthetic.nASSISTANTS: None.nINDICATION: The patient is a 40-year-old male with a history of acute onset of left foot pain. Ultrasound demonstrated a pseudoaneurysm versus aneurysm of the dorsalis pedis artery. The patient did not have any blue toes but based on the symptoms of pain and the location, it was recommended he undergo excision. Risks, benefits, and alternatives were discussed with the patient. He consented to procedure.nnDESCRIPTION OF PROCEDURE: On the operative day, the patient was met in the preop holding area. All site verification consent forms were completed and placed in the chart. The patient was then taken to the OR, placed on table in supine position. After induction of general anesthetic, the patient was prepped and draped in usual sterile fashion. Final time-out was then performed by all in attendance to be correct patient, correct procedure, correct site, and the antibiotics had been administered. Using ultrasound, the anterior tibial and dorsalis pedis artery were mapped. Of note, right at the ankle, the dorsalis pedis branched into a medial and lateral branch. The lateral branch was the one that proceeded on to the aneurysmal region. This area again was marked on the skin. At this point, a sterile pulse ox was placed on the great toe and hooked up to the machine for continuous monitoring. An incision remained over the marked area after the area was anesthetized with lidocaine and Marcaine mix. This was carried down through soft tissue using electrocautery. The retinaculum was identified and divided and neurovascular bundle exposed. The dorsalis pedis just distal to the medial branch was vessel looped and a test clamp was performed. This resulted into no deficit of the waveform or pulse oximetry reading in the great toe. Additionally, he had excellent color and signal distal to this test ligation. At this point, I traced distally along the artery until the aneurysmal portion was identified. It was noted that there was no Doppler signal or flow within this vessel in this position. At this point, I then carried the incision down to more normal appearing vessel and then placed 2 clips. This was then removed and opened on the back table revealing some atheroma. At this point, the incision was irrigated. Hemostasis was assured. It was closed in multiple layers with Vicryl and a Monocryl suture. Sterile dressing was applied in addition to Steri-Strips. The patient tolerated the procedure well. No complications.nnESTIMATED BLOOD LOSS: 5 cc. TOTAL FLUIDS: 600 mL.nTOTAL LOCAL: 9 mL.nSPECIMEN: Left dorsalis pedis artery to pathology.
Feb 4, 2021 | Uncategorized
What will the “Next Haven Healthcare” look like? Let’s ask the professionals! After the failed joint venture announced the disbanding of the employer healthcare, you may have questions about the future of employer healthcare and what it might look like. Speaking to five healthcare executives, continue reading below to see what they said about the future of employer-provided healthcare. nnHealthcare executives share their thoughts on how the next big disruptor will be perceived by the industry and the steps that organizations will need to take to succeed. It was only three years ago that Amazon, Berkshire Hathaway, and JPMorgan Chase joined together to form Haven Healthcare in an effort to improve employee healthcare options. When Haven was initially announced, it was surrounded by media fanfare and many thought the joint venture would disrupt the healthcare payers market. However, the business giants announced last month that Haven would disband by the end of February. Speculation around why the joint venture failed include lack of traction towards goals, unfocused execution of organizational strategy, a high turnover rate in the C-suite, and the fact that disruption healthcare is not an easy feat. Haven is not the first company to attempt to disrupt the healthcare industry and it certainly won’t be the last. Given the likelihood that another company will attempt to be the ‘next Haven,’ HealthLeaders spoke with five healthcare executives about how the next big disruptor will be perceived by the industry and what steps such an organization should take to succeed in this tough endeavor.nn‘ABSOLUTE AND MANIACAL TRANSPARENCY’nnAshok Subramanian, CEO of Centivo, an employee health plan, says he believes the next Haven, or an organization that self-styles itself as the next Haven, will be “viewed skeptically.” “Given that Haven tried to come out with great fanfare, and then was not able to be successful, naturally breeds skepticism,” he says. Subramanian adds that there is growing skepticism among the provider community of employers following a top-down approach to healthcare reform and “declaring that they are going to be successful.”nn”What we are seeing is enthusiasm for more bottom-up approaches, employers working with organizations to take matters into their own hands,” he says. “That, like a lot of community-driven efforts, will probably be viewed more positively than any organization that would at least label itself as the next Haven.” Subramaniam suggests organizations should focus on transparency and the “true spirit of the partnership.”nn”Nothing in this industry can successfully move the needle without a commitment to absolute and maniacal transparency around financial flows, around data, around understanding that ultimately employers who are self-funded are responsible for their own health plans. And that was one of the greatest failures of the first Haven,” he says. According to Subramaniam, organizations should collaborate “community by community” with providers that have committed to move the industry towards value-based care and willing to “collaboratively partner with agents of change.” He says these organizations are accepted over “large organizations who feel like they can fix these things on their own.”nnHAVEN’S DEMISE BREEDS CAUTIONnnMichael Abrams, managing partner and co-founder of Numerof & Associates, a healthcare management consulting company, says he also believes the next big industry disruptor will be viewed with uncertainty. “In many ways, I think the demise of Haven made it that much more difficult for any organization to claim that same mantle,” Abrams says. “They brought so much firepower to their announced mission of more or less fixing healthcare, that now that they’ve closed their shop, the industry may very well take it as an admission that the problem is just not solvable, because it couldn’t be solved by those superstars.”nnHe also says that while obstacles remain, there is no lack of disruptors currently working in the market. “There is a long list of disruptors that are working to come up with innovations that will make the money, and in most cases, lower the cost of care,” he says. Among those disruptors, Abrams explained, are Amazon, (which was one-third of the partnership behind Haven), and the U.S. government. To disrupt and change healthcare, he says organizations need to look towards those who are making waves in the industry. “To change the rules of the game will take a level of political will,” Abrams said. “That is the closest approximation to a big idea and will actually change healthcare.”nnNEED A UNIFORM STRATEGYnnWhen it comes to healthcare disruptors, Craig Maloney, CEO of Maestro Health, a third-party administrator for employee benefits, says he believes the focus should be on the members served. “I’m a big believer in starting with the consumer,” Maloney says. “So many of the end users, whether it’s my 80-year-old mother, the Gen Xers, or even people in healthcare [have] so much confusion. Anybody coming into this space needs to be able to impact that digesting healthcare on a daily basis.”nnHe adds: “You also have to serve the employer groups, since they’re the drivers of so much of the healthcare delivery out there today. Anytime you talk about transformation; it comes with risk. You need to be able to digest that risk, and tolerate that risk, to facilitate change.” Maloney says for the next big disruptor to succeed, they should have a uniform strategy, a focus on not only technology but also on “the human side of things” and “the wherewithal to commit” for a long period of time. “Haven proved out that three years is not a long commitment in terms of disrupting such an established, complex, and even odd industry,” Maloney says. “When [I] talk to other organizations who are looking to impact and change healthcare, [they’re looking at a 10-, 15-, or 20-year commitment.]” When organizations are first starting out, Maloney suggests they start small instead of starting big.nnFOCUS ON THE CUSTOMER EXPERIENCEnnMark Nathan, CEO of Zipari, a technology company specialized in health insurance, says the next big disruptor should work in conjunction with payers and providers to succeed in their mission of disrupting the healthcare space. “Payers and providers have to be part of the equation,” Nathan says. “Payers and providers have made huge investments in their systems. There’s a lot of regulation and emphasis on keeping everything running efficiently, but not a lot of emphasis on innovation. And so, to build that next generation of disruption for healthcare, they have to be at the table solving the problem.”nnHe also says there should be a focus largely on customer experience to succeed, including consistent communication and messaging. “The patient at the center of everything,” Nathan says. “We have to get that alignment between the payers, the providers, and a patient. No matter where the member engages with the payer, they should get a consistent message that’s going to … improve their health. If payers get that message up to their members, then the payer brands will start to improve, their Net Promoter Score will start to improve because they’ll be trusted. That’s something that’s missing in this industry that is critically important.”nn‘VERY PESSIMISTIC’ ABOUT THE NEXT HAVENnnSteven Goldstein, MD, founder of Houston Healthcare Initiative, a website which offers resources to people and organizations who want to change the current healthcare industry, is not optimistic for disruptors who want to change the current healthcare system through technology and innovation.nn”If we go back to first principles, the primary purpose of healthcare is to keep patients well,” Goldstein says. “The secondary purpose is to care for people when they get sick. But our current system is backwards, it primarily cares for the sick, and only secondarily tries to keep the patients well. The current system of managed care frowns on innovation. In my opinion, delivery of medical care lags the technology by about 25 years. They’re not innovative, they don’t want to change the system, and that’s the problem.”nnGoldstein notes that it is difficult for disrupters to succeed in the current system. “I’m very pessimistic that we’re going to get much innovation, like the Haven ideas, accepted by the healthcare industry in the current way it’s set up,” he says.nn nnOriginal article published on healthleadersmedia.com
Feb 4, 2021 | Uncategorized
Johnson & Johnson’s new Covid-19 Vaccine awaits approval and it is important to look at the coding and billing ahead of time. New vaccine CPT codes have been released for the vaccine and staying up to date will keep you in best practice once the vaccine is distributed. Read below to get the full story. nnAs new COVID-19 vaccines continue to be approved and distributed it is important to make sure you are correctly coding, and billing based on the vaccine given.nAhead of the approval of the new Johnson and Johnson COVID-19 vaccine, the AMA has added a new CPT code 91303 (Severe acute respiratory syndrome coronavirus 2 [SARS-CoV-2] [COVID-19] vaccine, DNA, spike protein, adenovirus type 26 [Ad26] vector, preservative free, 5×1010 viral particles/0.5 mL dosage, for intramuscular use).nnIn addition to this new vaccine code, there is also a new HCPCS code 0031A (Immunization administration by intramuscular injection of SARS-CoV-2 [COVID-19] vaccine, DNA, spike protein, Ad26 vector, preservative free, 5×1010 viral particles/0.5 mL dosage, single dose) for administration.nnThis code will take affect immediately following approval of the vaccine by the Food and Drug Administration (FDA). As of this writing, it is still pending approval.
Jan 28, 2021 | Uncategorized
nnWhat the rev cycles need to know about the “No Surprises Act” can help with understanding the new legislation coming January 2022. The legislation is set to protect patients from surprise medical bills and provide protections within network care. Continue reading below to keep yourself updated on the new legislation. nnJust as revenue cycle executives are coming up for air from the CMS price transparency mandate, they have another date to add to their compliance calendar: January 1, 2022. That’s the day that the No Surprises Act goes into effect. The legislation has two main parts. First, it protects patients from surprise medical bills. “Under the recently announced No Surprises Act, patients will only have to pay the in-network cost-sharing responsibilities for their care, while payers and providers will negotiate payment for the rest,” Rob LaHayne, CEO of TouchCare, a healthcare concierge service, tells HealthLeaders via email.nnThe No Surprises Act also establishes an independent dispute resolution (IDR) process for payers and providers. “It takes consumers out of the middle of the dispute between the payer and the provider,” says Becky Greenfield, partner with Wolfe Pincavage, a Miami law firm specializing in healthcare, insurance coverage, and business law.nnARBITRATION 101nThe IDR will use a “baseball-style” arbitration to settle disputes between payers and providers. Each of the parties will offer a payment amount, and an independent arbitrator will choose one offer or the other, rather than an amount in between. “That incentivizes those parties to [each] make a reasonable offer,” Greenfield says. This so-called “final-offer arbitration” process can help prevent the parties from making bids that are either too high or too low.nn”The incentive created by arbitration brings some elements of market dynamics into the dispute-resolution process,” says Benjamin L. Chartock, associate fellow at the Leonard Davis Institute of Health Economics and lead author of a recent Health Affairs study about arbitration in out-of-network medical bill payment disputes in New Jersey. “A more extreme offer by one of the parties in arbitration helps them financially if they win but might lower the probability that they win.” In advocating for a dispute resolution process, hospitals had been pushing for arbitration, whereas payers had called for benchmark payments, such as ones tied to median in-network rates.nn”This process edges the surprise billing issue closer to the dispute resolution and regulatory structure common in many of today’s workers’ compensation structures, where most states removed patient liability well over two decades ago,” notes Scott Bennett, vice president of access innovation at Maestro Health, via email.nnCONSUMER PROTECTIONSnFrom a consumer perspective, the No Surprises Act essentially makes out-of-network balance billing a thing of the past. That’s especially important for patients who live in states that don’t already have such protections in place. According to the Commonwealth Fund, 18 states have no balance billing protections in place. The rest have comprehensive or partial protections. “It requires that insurers apply the in-network, out-of-pocket benefits to emergency services and [to] out-of-network services in in-network facilities,” Greenfield says, such as services provided by an out-of-network anesthesiologist working in an in-network facility. “Not only can you not be billed the difference between what the insurer pays and what the provider bills, you also cannot apply out-of-network deductibles to these types of services,” she says.nnAccording to an announcement from the U.S. Senate Committee on Health, Education, Labor & Pensions, the legislation:n
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- Holds patients harmless from surprise medical bills, including from air ambulance providers, by ensuring they are only responsible for their in-network cost-sharing amounts, including deductibles, in both emergency situations and certain non-emergency situations where patients do not have the ability to choose an in-network provider
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- Prohibits certain out-of-network providers from balance billing patients unless the provider gives the patient notice of the network status and an estimate of charges 72 hours prior to receiving out-of-network services and the patient provides consent to receive out-of-network care
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- Provides additional consumer protections when insurance companies change networks, including a transition of care for people with complex care needs and appeal rights for consumers
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- Provides a true and honest cost estimate that describes which providers will deliver their treatment, the cost of services, and provider network status
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nREVENUE CYCLE CONSIDERATIONSnAlthough the legislation won’t go into effect for nearly a year, there are things that revenue cycle executives should be thinking about and working on as they prepare.nn1. Establish processes to end balance billing: “First and foremost—especially if you’re not in a state that already has balance billing protections—you need to establish a process to make sure that patients are not balance billed,” Greenfield says.nn2. Get ready to provide estimates: Providers also must prepare to give patients a “true and honest cost estimate.” “Those processes need to be in place,” according to Greenfield. “[Revenue cycle] staff needs to be trained on this as well to make sure that they’re compliant, because there are civil monetary penalties involved for noncompliance.”nn3. Remember that arbitration costs money: Chartock notes that “arbitration is not free,” so providers need to consider their dispute resolution options. “Disputing parties have the option as well to resolve these payment disputes for out-of-network bills offline and, if I were in a situation like that, I would carefully consider doing that as well,” he says.nn4. Pay attention to the details: Although the No Surprises Act was signed into law, more details are still coming. For example, the Commonwealth Fund notes that “Federal officials will have to establish a list of eligible arbitrators and help interpret the factors that will guide arbitrators’ decisions.” “There is still a rule-making period that must take place between the passage of the law and when it begins to take effect,” Chartock says. “We know the text of the law, but not the intricate details of how the law will be enacted.”nn nnOriginal article published on healthleadersmedia.com
Jan 28, 2021 | Uncategorized
January is National Mentorship Month! This is the month of the year to celebrate mentorship for professional and personal development for individuals across the United States. As we wrap up January, think of how mentors in our lives have impacted us and how we can continue to mentor the future to make our communities stronger and healthier.nnOne of my favorite quotes; “We learn… 10% of what we read, 20% of what we hear, 30% of what we see, 50% of what we both hear and see, 70% of what is discussed, 80% of what we experience personally, 95% of what we teach to someone else” -William Glasser.nnEach year as you look to the future and the goals you hope to achieve in the new year, one cannot overlook how your goals can be enhanced through mentorship. Whether you choose to be a mentor or request mentorship from some else it is a great opportunity to gain knowledge and camaraderie in your goals and support someone else in theirs.nn“A mentor is someone who sees more talent and ability within you, than you see in yourself, and helps bring it out of you.” -Bob Proctor.n
Jan 21, 2021 | Uncategorized
CMS puts patients over paperwork with a new rule that addresses the prior authorization process. The new rule will empower patients, lower costs, and give providers the ability to give better care to their patients. Continue reading below to learn more about the new final rule.nnToday, the Centers for Medicare & Medicaid Services (CMS) finalized a signature accomplishment of the new Office of Burden Reduction & Health Informatics (OBRHI). This final rule builds on the efforts to drive interoperability, empower patients, and reduce costs and burden in the healthcare market by promoting secure electronic access to health data in new and innovative ways. These significant changes include allowing certain payers, providers and patients to have electronic access to pending and active prior authorization decisions, which should result in fewer repeated requests for prior authorizations, reducing costs and onerous administrative burden to our frontline providers. This final rule will result in providers having more time to focus on their patients and provide higher quality care.nn“Today, we take a historic stride toward the future long promised by electronic health records but never yet realized: a more efficient, convenient, and affordable healthcare system,” said CMS Administrator Seema Verma. “Thanks to this rule, millions of patients will no longer have to wrangle with prior providers or locate ancient fax machines to take possession of their own data. Many providers, too, will be freed from the burden of piecing together patients’ health histories based on incomplete, half-forgotten snippets of information supplied by the patients themselves, as well as the most onerous elements of prior authorization. This change will reverberate around the healthcare system for years and decades to come.”nnThe “CMS Interoperability and Prior Authorization” rule is the next phase of CMS interoperability rulemaking, aimed at improving data exchange while simultaneously reducing provider and patient burden. This final rule requires the payers regulated under this rule (namely, Medicaid and CHIP managed care plans, state Medicaid and CHIP fee-for-service programs (FFS) and issuers of individual market Qualified Health Plans (QHPs) on the Federally-facilitated exchanges (FFEs)) to implement application programing interfaces (APIs) that will give providers better access to data about their patients, and streamline the process of prior authorization. APIs are the foundation of smartphone applications, and when integrated with a provider’s electronic health record (EHR), they can enable data access at the touch of a button. By exchanging relevant health information between patients, providers and payers, APIs support a better health care experience for patients. Patients have easier access to their own health information, their providers have a more complete picture of their care, and patients can take their information with them as they move from plan to plan, and from provider to provider throughout the healthcare system. This ensures more coordinated, quality care, and less repetitive and unnecessary care that is costly.nnToday’s final rule requires Medicaid and CHIP (FFS) programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to include, as part of the already established Patient Access API, claims and encounter data, including laboratory results, and information about the patient’s pending and active prior authorization decisions. These payers are also required to share this data directly with patients’ providers if they ask for it and with other payers as the patient moves from one payer to another. In this way, patients, providers, and payers have the data when and where they need it, to help ensure that patients receive the best possible care. While Medicare Advantage plans are not included in and therefore not subject to this final rule, CMS is considering whether to do so in future rulemaking.nnPrior Authorization Burden ReductionnnPayers use prior authorization as a way to manage health care costs and ensure payment accuracy. For certain services, providers request approval from payers before rendering care to ensure that the payer will determine that the care is medically necessary, a threshold requirement for care to be reimbursed under the patients’ health coverage. This administrative process can be burdensome, and the challenges of the prior authorization process have motivated industry efforts to develop tools to increase automation. This final rule aims to reduce the inefficiencies and burdens of the prior authorization process for providers, and give them back time to focus on what matters most, treating patients in a timely manner.nnThe final rule requires Medicaid and CHIP FFS programs, Medicaid and CHIP managed care plans, and issuers of individual market QHPs on the FFEs to build, implement, and maintain APIs using the Health Level 7 (HL7) Fast Healthcare Interoperability Resources (FHIR) standard to support automation of the prior authorization process, specifically addressing the challenges raised by both providers and payers. The requirements of this rule specify that each of these payers will build an API-enabled documentation requirements look-up service, and make these public so providers may access documentation and prior authorization requirements from their EHR platforms. Once a provider knows what is required for each prior authorization, the next step is submitting it electronically. The final rule also requires Medicaid, CHIP, and QHP payers to implement and maintain prior authorization support APIs using the HL7 FHIR standard, which will advance a streamlined approach for communicating prior authorization requests and responses between those payers and provider EHR platforms or other practice management systems.nnThe final rule also requires Medicaid and CHIP (FFS) programs, and Medicaid and CHIP managed care plans to meet reduced decision timelines for prior authorizations. These payers will now have a maximum of 72 hours to make prior authorization decisions on urgent requests and seven calendar days for non-urgent requests, and all payers subject to the rule are required to provide a specific reason for any denial, which will allow providers some transparency into the process beginning January 1, 2024 or the rating period that starts on or after January 1, 2024. In addition, to promote accountability, the rule requires these payers, to make public, prior authorization metrics that demonstrate how they operationalize the prior authorization process. All of these requirements together will promote a more streamlined and efficient prior authorization process for providers and payers alike.nnThe rule will improve the patient experience as well. When a patient sees, for instance that a prior authorization is needed and has been submitted for a particular item or service, they will better understand the timeline for the process and be able to work with their provider to plan accordingly.nnToday’s final rule aims to improve longstanding inefficiencies in the healthcare system —including the lack of data sharing and access. This final rule expands the current Administration’s goals of quality and lower costs in health care as payers and providers will now have access to more complete patient histories, allowing for more coordinated and seamless patient care.n
Click here to review the final rule.
n nnOriginal article published on cms.gov
Jan 21, 2021 | Uncategorized
There is a new HCPCS code G2212 for prolonged services with or without direct patient contact on the date of service. This new code has changes that influence when extra time starts during patient encounters. Continue reading below to learn more.nnWith All the changes come up in 2021 for Office and Outpatient encounters, if you are a CMS credentialed provider this topic cannot be emphasized enough. Part of the overhaul of the Evaluation and Management (E/M) guideline changes was the creation of a prolonged service code, 99417. Unfortunately, the requirements for this code will not be support by CMS, thus the creation of HCPCS code G2212. Below you will see two tables taken directly from CMS Manual, transmittal 10505.nnThe biggest difference is that extra time does not start once the maximum time for your base code, 99205 or 99215, has been exceeded but rather it begins at minute 89. (i.e. if your total encounter time for a particular encounter was 100 minutes, according to CPT you would report 99205 + 99417×2 vs. CMS you would report 99205 + G2212x1).nnThese charts should be printed out and added to you CPT manual for comparison to what AMA has released for code 99417 or kept in with your other quick reference tools.nn nnnn n
Click here to view the CMS Manual System
Jan 18, 2021 | Uncategorized
A new year means new CPT changes have been released. These changes apply to E/M office and other outpatient visit reporting. We’ve compiled a list of 30 FAQ’s so that you can start your 2021 reporting off right. Continue reading below to learn more.nnBy Ginger Avery, CPC, CPMA, CRCnJanuary 5, 2021nn1.Where can the CPT E/M code and guidelines be found? The CPT E/M code and guideline changes for 2021 can not only be found on the American Medical Associations (AMA) site at this link, but they can also be found in their entirety within the 2021 CPT Code books themselves. These guidelines include the new level of medical decision-making table and the 22 new definitions that help clarify what the MDM terms mean.nn2.Does pulling the lab results into the note constitute a “review of results” or do I need to document by stating that I have reviewed them? Moving forward information from old notes without comment does not add any value to the work that was performed and does not count. Did you review/analyze these results, what impact does this have on today’s visit? What is the clinical significance of this additional work?nn3.When tests are ordered during one visit and reviewed the same test during the next visit, can that count as a data point for both visits? With the new guidelines, we no longer have data “points”. Both encounters would support Limited data (low) with Category 1. The first encounter supports Category 1 for ordering of the test, the follow up encounter would support Category 1 for review of the results.nn4.Where does lifestyle counseling come into this? Preventive medicine counseling and/or risk factor reduction interventions (99401-99412) are time-based codes but do NOT follow the office visit E/M guidelines. Relevant visit details and total F2F time should be documented appropriately. Code selection is based on the F2F time spent with the patient.nn5.When reporting for total time, is it just time spent with patient at the encounter? No, in 2021, time is defined as the total encounter time on the date of service. This includes both F2F work and non-F2F work personally performed by the clinician.nn6.When dealing with complex patients where time is difficult to track will we have to revert to Medical Decision Making? With the new guidelines, you now have a choice, MDM or total encounter time. If total encounter time runs outside of the date of service or is challenging to track, then reporting based on the medical decision making may be a better choice. Do not undervalue the complexity by not documenting all the relevant work you do.nn7.Seeing how we cannot estimate for time that could be spent, say for a possible follow up phone call, how should we code to earn credit for that work? Time based reporting is only appropriate for time spent on the date of the encounter. Follow up phone calls on a later date cannot be reported based on time. MDM should be considered. In column 2 of the level of MDM chart, Category 3 provides credit when discussing the case with other clinicians or appropriate source. Be sure to document these details when true.nn8.Providers do use outpatient codes in the hospital if patient is in Observation status “not Inpatient”, I would assume these rules would apply to bill new/vs est pt when appropriate? Yes, the guideline updates are for office visits and other outpatient services.nn9.With the new time-based reporting, it seems that we absolutely need to sign off on our notes on the day of service. This is not always feasible given a busy day. In 2021, total encounter time includes completing documentation. If a clinician is unable to complete their note on the date of the encounter, reporting based on MDM may be a better choice.nn10.Some of these activities occur after the visit (complications/adverse reactions) – how can you account for that in your note for that day? Complications and adverse reactions may support an additional encounter when the need for evaluation and management may arise but would not be included on the date of the encounter unless that presentation was true during the visit.nn11.Do the E/M changes apply to outpatient or inpatient services? The 2021 E/M changes only apply to Outpatient services. Inpatient visits still need to follow the key component guidelines (1995 or 1997).nn12.Since history and physical exam are no longer required to level the visit, should these elements still be documented? Yes, history and exam are still part of an evaluation. The documented content should be focused on the clinically relevant details and cognitive thoughts of the clinician, not checkboxes or templated details. What is the nature of the presenting illness(es) (subject details with pertinent ROS)? Document a medically necessary exam. Documentation is about the quality of the story, not the quantity of details. Don’t import pages of past medical history or medication lists that aren’t relevant. Clinicians are encouraged to write notes that they would like to read.nn13.Do I still have to document ROS and PFSH? Yes, when clinically relevant. For example: Patient presents with chest pain. Has been having intermittent chest pain at rest for two weeks. No notable triggers. Positive for headaches and dizziness, no SOB. Patient has a past family history of CAD. Remember, documentation is all about the medically necessary story.nn14.When coding based on total time does the assessment and plan still need to be documented? Yes. Quality documentation should always be captured. Clinical impressions and plans that are well documented support the medical necessity for the services provided, regardless of how you choose to report the visit. Again, clinicians are encouraged to write notes that they would like to read.nn15.When coding based on total time and have also provided additional time-based services (advance care planning, counseling, etc.) how should those services be documented? The time associated with each visit should be separate and clearly identified to support each unique service.nn16.Are commercial plans required to adopt the revisions to E/M codes? Yes. The CPT code set, together with the U.S. Department of Health and Human Services’ Healthcare Common Procedure Coding System, has been adopted as the nation’s standard medical data code set. HIPAA requires that health plans use the most recent version of the medical data code set, they should be ready to implement the revisions Jan. 1, 2021.nn17.Who else besides clinicians needs to implement the 2021 E/M office visit changes? Other clinicians, coders, third-party plan administrators, and other health care-related entities should start using the revised code set Jan. 1. Physician practices should confirm that their contracted health plans and EHR vendors are integrating the revised codes into their software systems and will be ready Jan. 1, 2021.nn18.Can I still use my EHR’s coding calculator? Technically, Yes. It is important that clinicians confirm with their EHR vendor that their system’s code-selection application conforms to the revised codes and descriptors because the billing provider has the ultimate responsibility for appropriate coding. The EHR’s coding calculators are simply bean counters driven by templates and checkboxes; medically necessity cannot be quantified utilizing a point counting system. Often these systems are not set up with the appropriate guidelines and do not include additional instruction.nn19.Can we still bill 99201-99205 and 99211-99215 based on the 1995 and 1997 guidelines for dates of service on and after January 1, 2021? Office/outpatient visits PRIOR to January 1, 2021 may still be billed using the 1995 or 1997 guidelines. Clinicians must bill office/outpatient visits provided ON or AFTER January 1, 2021 using the CPT E/M code and guideline changes for 2021. Note: Based on the CPT changes, code 99201 is no longer valid for dates of service on and after January 1, 2021.nn20.Do the 2021 E/M code and guideline changes apply to all categories of E/M services? No. The E/M code and guideline changes are specific for office and other outpatient visits and apply only to codes 99201–99205 and 99211–99215.nn21.For dates of service on and after January 1, 2021, how are the levels of E/M services provided in an office/outpatient setting determined? For dates of service on and after January 1, 2021, select the appropriate level of E/M service based on the following (you choose): The level of the medical decision making as defined for each service; OR the total time personally spent by the clinician for all services related and dedicated to that patient on the date of the encounter.nn22.Does the revised medical decision-making table for 2021 provided by the AMA apply to all E/M services? No. The CPT E/M code and guideline changes for 2021 and subsequent MDM table only apply to office/outpatient E/M services beginning January 1, 2021. All other E/M categories and codes continue to follow the 1995 and/or 1997 E/M guidelines. However, the additional clarification provided in the new guidelines displays the importance of documenting clinically significant details (medically necessary), avoiding templated checkbox information and provides definitions for many of the terms on the table of risk to help the reader understand appropriate considerations of Medical Decision Making.nn23.Is the documentation of history and examination required when scoring office/outpatient services under the revised 2021 guidelines? The approved revisions do not materially change the three current MDM elements, but instead provide extensive edits to the elements for code selection and revised or created numerous clarifying definitions in the E/M guidelines. While the provider’s work in capturing the patient’s pertinent history and performing a relevant physical exam contributes to both the time and medical decision making, these elements alone should not determine the appropriate code level. The revised code descriptors state a “medically appropriate history and/or examination” is required.nn24.Is time defined differently for office and outpatient E/M services effective for dates of service on and after January 1, 2021? According to the AMA, for dates of service on and after January 1, 2021, time is defined as minimum time, not typical time, and represents the total encounter time personally spent by the clinician on the date of service. This definition applies only when code selection is based on time and not MDM.nIs time defined differently for office and outpatient E/M services effective for dates of service on and after January 1, 2021? According to the AMA, for dates of service on and after January 1, 2021, time is defined as minimum time, not typical time, and represents the total encounter time personally spent by the clinician on the date of service. This definition applies only when code selection is based on time and not MDM.nn25.When coding by time, is the day of encounter by calendar date or 24-hour period? When coding by time, only the time spend on the actual calendar date of the encounter is applicable.nn26.How is time counted under the CPT E/M code and guideline changes for 2021? Except for code 99211, per AMA, beginning with CPT changes 2021, time alone may be used to select the appropriate code level for the office or other outpatient E/M service codes (99202-99205, 99212- 99215). Time may be used to select a code level in office or other outpatient services regardless or not counseling and/or coordination of care dominates the service. When time is used to select the appropriate level for E/M service codes, time is defined by the service descriptors. The E/M services for which these guidelines apply require a face-to-face encounter with the clinician. For office or other outpatient services, if the clinician’s time is spent in the supervision of clinical staff who perform the face-to-face services of the encounter, use code 99211.nn27.What activities can be counted towards total clinician time? Time includes the following activities when personally performed by the clinician:n
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- Preparing to see the patient (e.g., review of tests).
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- Obtaining and/or reviewing separately obtained history.
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- Performing a medically appropriate examination and/or evaluation.
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- Counseling and educating the patient/family/caregiver.
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- Ordering medications, tests, or procedures.
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- Referring and communicating with other health care professionals (when not separately reported).
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- Documenting clinical information in the electronic or other health record.
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- Independently interpreting results (not separately reported) and communicating results to the patient/family/caregiver.
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- Care coordination (not separately reported).
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n28.How do other requirements (e.g., teaching physician, incident to, new vs. established) apply when using the CPT E/M guidelines for 2021? CMS is adopting the AMA’s guidance on coding office/outpatient E/M visits. Most rules remain unchanged.nn29.Can the independent visualization of a test be counted in the medical decision making if the physician is also billing for the test? Per AMA, the actual performance and/or interpretation of diagnostic tests/studies during a patient encounter are not included in determining the level of E/M service when reported separately. Clinician performance of diagnostic tests/studies for which specific CPT codes are available may be reported separately, in addition to the appropriate E/M code. The clinician’s interpretation of the results of diagnostic tests/studies (i.e., professional component) with preparation of a separate distinctly identifiable signed written report may also be reported separately, using the appropriate CPT code and, if required, with modifier 26 appended. If a test/study is independently interpreted in order to manage the patient as part of the E/M service but is not separately reported; it is part of medical decision making.nn30.When considering High Risk MDM, there is an example listed: “drug therapy requiring intensive monitoring for toxicity”. What constitutes supporting this definition? When considering this complexity, both the drug and the monitoring must qualify. The new guidelines provide this definition when considering this High Risk example: “Drug therapy requiring intensive monitoring for toxicity: A drug that requires intensive monitoring is a therapeutic agent that has the potential to cause serious morbidity or death. The monitoring is performed for assessment of these adverse effects and not primarily for assessment of therapeutic efficacy. The monitoring should be that which is generally accepted practice for the agent but may be patient specific in some cases. Intensive monitoring may be long-term or short term. Long-term intensive monitoring is not less than quarterly. The monitoring may be by a lab test, a physiologic test or imaging. Monitoring by history or examination does not qualify. The monitoring affects the level of medical decision making in an encounter in which it is considered in the management of the patient. Examples may include monitoring for a cytopenia in the use of an antineoplastic agent between dose cycles or the short-term intensive monitoring of electrolytes and renal function in a patient who is undergoing diuresis. Examples of monitoring that does not qualify include monitoring glucose levels during insulin therapy as the primary reason is the therapeutic effect (even if hypoglycemia is a concern); or annual electrolytes and renal function for a patient on a diuretic as the frequency does not meet the threshold.”nnAs a reminder, documentation is about painting a clear picture of today’s encounter. The power of storytelling is evident with these new revisions. Quality documentation (not quantity or checkboxes) provides details to support the medical necessity and appropriate complexity of each unique encounter, as well as improves overall patient care and clinical outcomes. Clinicians are encouraged to focus their energy and documentation on the cognitive clinically relevant details, regardless of the clinical setting. Document what you do, code what you document.nn Welter Healthcare Partners provides robust coding and documentation training for these updates, as well as other topics. Please contact cwhitworth@rtwelter.com to book your training now.nnReferences:nAMA CPT® E/M Code and Guideline Changes for 2021nAma-assn.orgnNovitas E/M Documentation RequirementsnNoridian E/M Documentation Requirements
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