Feb 19, 2020 | Uncategorized
In a recent release of 2018 benchmarks regarding modifiers 76, 77 and 79, the data of payment vs denials is staggering. For instance, a total of 159 codes reported with 91 and 249 codes that were reported using modifier 77 all had a 100% denial rate. Compared to the 952 codes that were denied when reported with 76 that doesn’t seem so bad. But considering your bottom line and the time it takes your team to resubmit it adds up to money lost. nnHowever when we step back and look at the big picture we see that modifier 76 although the most reported, still had the lowest overall denial rate at just 5%.n
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n
n
| Modifier |
n
Times Reported |
n
Percentage Denied |
n
Total Denied |
n
Total Paid |
n
n
n
| 76 |
n
119,200,000 |
n
5% |
n
5,960,000 |
n
113,240,000 |
n
n
n
| 77 |
n
706,223 |
n
14% |
n
98,871 |
n
607,352 |
n
n
n
| 91 |
n
3,000,000 |
n
20% |
n
600,000 |
n
2,400,000 |
n
n
n
n nnWatching your reporting trends and utilizing billing reports will help make sure you avoid costly denials. Be aware of National Baselines for your specialty and where you fall within them.
Feb 14, 2020 | Uncategorized
2021 brings us monumental changes to Evaluation and Management coding and reporting! Notable changes will include: Deletion of CPT code 99201, new time reporting guidelines and modifications to criteria for medical decision-making.
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The new guidance also includes a revision to the work relative value units (RVU) for E/M office visits to match up with the AMA’s RVU Update Committee revised rates and increases total payments for most office codes.
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It is important to start planning your transition and training today so your practice is not at risk for delayed or lost revenue. To support your transition and training needs, we have developed the CHIEF Implementation Plan for 2021 E/M Changes! Click here for more details and contact us to get started!
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Feb 14, 2020 | Uncategorized
As Risk Adjustment (RA) and Hierarchical Condition Category (HCC) coding continue to grow and become common practice it is important for not just coders, but also our clinicians to recognize its importance and the effect it has on reimbursement. Below is an example of a procedure and notes regarding coding and why our clinician must be queried in order for the claim to be submitted. Do you have a complicated surgery case that needs help with coding? Welter Healthcare Partners would love to help! Please upload the operative note by clicking on the link below. Remember to remove ALL patient protected health information and organization identifiers. Welter Healthcare Partners will not use any medical records submitted in which PHI is not removed and protected. – Click Here to Submit Redacted Surgery Case Study –nnDATE OF SURGERY: XX/XX/19n
PREOPERATIVE DIAGNOSIS: Left foot necrosis, as well as heel ulcer. PROCEDURES:
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- Left foot transmetatarsal amputation.
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- Left foot heel debridement, extensive.
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nNOTE: Documentation gives the impression that PT may have DM. Per correct coding guidelines, in order to code for peripheral vascular disease, we need to know if this is in relation to a Dx of diabetes mellitus as it effects code selection. Also, in order to code for heel debridement, surface area and depth must be documented (code 11043 can be reported and possibly 11046 if applicable).nnPOSTOPERATIVE DIAGNOSIS: Same.nnASSISTANT: A. SMITH, SA-C. nnANESTHESIA: Peripheral nerve block with MAC. ESTIMATED BLOOD LOSS: 25 mL.nnINTRAVENOUS FLUIDS: One L crystalloid. SPECIMENS REMOVED: Foot sent to path. COMPLICATIONS: None.nnDISPOSITION: To recovery room in good condition.nnFINDINGS: The patient was found to have left near full-thickness heel ulcers with no exposed bone. She also had necrosis of the entire forefoot.nnINDICATIONS: This is a 55-year-old female, with extensive peripheral vascular disease, who was deemed a surgical candidate for the stated procedure. Risks and benefits were discussed at length with the patient, including, but not limited to, infection, bleeding, neurologic injury, vascular injury, pain, stiffness, a possible need for further surgery. I personally marked the patient’s operative extremity prior to proceeding forth to the operating room.nnOPERATIVE REPORT: The patient was brought to the operating room on a gurney. She underwent peripheral nerve block per the anesthesia service. She was placed in the supine position and underwent MAC anesthesia. The left lower extremity was sterilely prepped and draped, using pure alcohol scrub and ChloraPrep.nnFollowing timeout confirming the correct patient, procedure, and extremity, the heel ulcer wounds were debrided. These were through the fascial layer, but not down to the bone. These were debrided back to bleeding tissue.nnWe then performed a transmetatarsal amputation by making a skin incision along viable skin. The subcutaneous tissues were stripped back to a planned osteotomy site with an oscillating saw. There was osteotomy performed along the proximal metatarsals. The specimen was sent to the path lab. We then checked for bleeding. There was bleeding at this level. This was irrigated out with 3 L normal saline mixed with bacitracin. Then with no tension, the plantar fat pad was repaired to the metatarsals. The skin was closed with 2-0 Monocryl and 2-0 nylon along with no tension. A sterile dressing was placed. The patient was then extubated and brought to the recovery room, with no further complications.nnPlease note that A. SMITH, SA-C, a skilled surgical assist, was an absolute requirement due to the complexity of this procedure. He did participate in wound exposure, retraction, and closure at the conclusion of the case.
Feb 7, 2020 | Uncategorized
During the State of the Union address, President Trump discussed the price transparency rule and slammed Medicare for all. Below are some of the main points President Trump made during the speech which included drug pricing plans, association health plans, and more. Read below for more information!nnPresident Donald Trump delivered his third State of the Union address Tuesday night, elaborating on several of the administration’s major healthcare initiatives.nnUnlike his previous two State of the Union speeches, Trump mainly avoided discussing the Affordable Care Act and instead focused on new policies like the administration’s price transparency rule and efforts to lower prescription drug prices.nnTrump also did not discuss the Health Adult Opportunity initiative, which was announced by the Centers of Medicare & Medicaid Services (CMS) last week.nnHe did criticize proposals to institute a ‘Medicare for All’-style system, which has been embraced by several Democratic presidential candidates.nn”To those watching at home tonight, I want you to know we will never let socialism destroy American healthcare,” Trump said.nnBelow are the healthcare policies discussed during Trump’s speech, including reaction from industry stakeholders to his remarks.nnPotential impact of price transparency rulennTrump heralded the administration’s price transparency rule, which will go into effect in 2021, saying it will save families “massive amounts of money for substantially better care.”nnHe also added that experts believe the rule, which is being challenged in a lawsuit by provider organizations, “will be even bigger than healthcare reform.”nnOn the topic of improved price transparency, Trump said patients should never be “blindsided” by medical bills but did not address the issue of surprise medical billing, which has stalled on Capitol Hill in recent months.nnOffensive against Medicare for AllnnTrump attacked Medicare for All proposals that have been put forward by congressional leaders, warning that such policies will “take away your healthcare, take away your doctor, and abolish private insurance entirely.”nn”132 lawmakers in this room have endorsed legislation to impose a socialist takeover of our healthcare system, wiping out the health insurance plans of 180 million very happy Americans,” Trump said.nnIn addition to his critiques of Medicare for All, Trump assailed California Governor Gavin Newsom’s recent proposal to extend public healthcare coverage to undocumented immigrant seniors.nn”These proposals would raid the Medicare benefits of our seniors and that our seniors depend on while acting as a powerful lure for illegal immigration,” Trump said.nnCalls on Congress for bipartisan drug pricing plannnOn the prescription drug front, Trump highlighted the administration’s challenge to the pharmaceutical industry and pointed to the record number of generic drugs to receive approvals from the Food and Drug Administration last year.nnHe said that last year marked the first time in 51 years that prescription drug prices went down but added that Congress can do more to lower prescription drug prices.nnTrump specifically referenced conversations he has had with Senate Finance Chairman Chuck Grassley, R-Iowa, who recently told Stat News that Trump has not advocated enough for a bipartisan drug pricing bill he coauthored with Ranking Member Sen. Ron Wyden, D-Ore.nn”I am calling for bipartisan legislation that achieves the goal of dramatically lowering prescription drug prices,” Trump said. “Get a bill on my desk, and I will sign it into law immediately.”nnSome Democratic House representatives vocally rebuked Trump’s points on drug pricing, expressing support for the Elijah E. Cummings Lower Drug Costs Now Act, which passed in the chamber in December.nnPraise for association health plansnn
Trump mentioned the administration’s move to introduce association health plans (AHP), saying the options are “60% less expensive, and better” than other available forms of coverage.nn”A good life for American families also requires the most affordable, innovative, and high-quality health system on Earth,” Trump said.nnTrump did not mention the ruling by a federal judge last spring that blocked key provisions of AHPs and the administration’s subsequent decision to file an appeal.nnProtect Medicare and patients with pre-existing conditionsnnDespite not mentioning the ACA, or its uncertain status due to a pending legal battle, Trump promised to protect patients with pre-existing conditions.nn”I have also made an ironclad pledge to American family: We will always protect patients with preexisting conditions,” Trump said.nnHe added that the administration will “always protect” Medicare.nnTrump also reiterated the administration’s commitment to improving kidney care and eradicating HIV by 2030.nnIndustry reaction to speechnnFollowing the address, stakeholders weighed in on the president’s remarks, expressing both support and criticism of the administration’s direction on healthcare policy.nnElizabeth Mitchell, CEO of the Pacific Business Group on Health, told HealthLeaders that business leaders are primarily concerned about policy proposals that ensure drugmakers, payers, and providers “don’t use anti-competitive practices to gain market power and raise prices.”nn“Employers are fed up with high drug costs and high healthcare costs generally,” Mitchell said in a statement to HealthLeaders. “They’re doing everything they can to be effective purchasers on behalf of their employees, but they don’t have adequate negotiating leverage with monopoly drug manufacturers. We need policymakers to stop manufacturers from egregious pricing and anti-competitive practices.”nnRep. Greg Walden, R-Ore., Ranking Member on the House Energy and Commerce Committee, said he had not seen a president “lean in further” on “lowering health care costs.”nn”President Trump is committed to driving down the cost of unaffordable prescription drugs; he is committed to helping American families. This stands in stark contrast to the command and control view of many in the Democratic Party today,” Walden said in a statement.nnContrasting Walden’s remarks, Rep. Lloyd Doggett, D-Texas, Chairman of the House Ways and Means Committee, said Trump has “failed to do anything to actually lower prices for anyone.”nn”Instead of slashing prices, Trump slashes Americans’ healthcare. He seeks to terminate Affordable Care for millions, end protections for patients with pre-existing conditions, and wreck Medicaid, while promoting ‘junk insurance’ and claiming to have a secret replacement plan,” Doggett said in a statement.nnThe Campaign for Sustainable Rx Pricing (CSRxP), which includes America’s Health Insurance Plans and the American Hospital Association as members, tweeted its approval of Trump’s call for a plan to lower prescription drug prices.nn”President @realDonaldTrump is right to call on Congress to lower #drugprices and hold #BigPharma accountable,” CSRxP tweeted. “The American people are watching to see if lawmakers can rise above politics and the influence of #BigPharma to pass bipartisan, market-based drug pricing solutions.”nnJack O’Brien is the finance editor at HealthLeaders, a Simplify Compliance brand.nnOriginal article published on healthleadersmedia.com
Feb 7, 2020 | Uncategorized
In the January 23rd edition of the MLN Connects, CMS announced the release of a Comparative Billing Report (CBR) on Shoulder Arthroscopies for Medicare part B claims. This information can be vital for Orthopedic practices during the audit process. Data will be compared based on other providers in your state as well as nationwide. However, this information is not available publicly so you must login to make sure your contact information is up to date. You can also visit the CBR website for more information. Never visited the CBR website? We strongly recommend you do, as this site contains great information about all specialties.nnnThe Comparative Billing Report (CBR) contains data-driven tables with an explanation of findings that compare your billing and payment patterns to those of your peers in your state and across the nation.nnCBRs are not publicly available. Look for an email from cbrpepper.noreply@religroupinc.com to access your report. Update your contact email address in the Provider Enrollment, Chain, and Ownership System to ensure accurate delivery. Visit the CBR website for more information.nnOriginal article published on cms.gov
Jan 27, 2020 | Uncategorized
Recently, there has been a new healthcare scorecard that is evaluating the cost-saving policies in Colorado. Read the article below to see where Colorado ranks and what the state is doing to make healthcare more affordable to those living here!nnColorado is doing well to make out-of-pocket healthcare costs affordable and transparent but does not have policies in place to reduce the unnecessary provision of care, a new analysis of state healthcare policies found.nnAltarum, a research and analytics consultancy, released data on Tuesday ranking the policies and healthcare outcomes of states on four metrics, including in the areas of reducing prices and extending coverage to all residents.nn“In 2018, Colorado was in the middle third of states in terms of covering the uninsured, ranking 25 out of 50 states, plus D.C.,” the scorecard states, adding that Medicaid coverage for childless adults extends to 138% of the federal poverty line.nnThe scorecard also gave Colorado high marks for reducing Cesarean-section births for low-risk mothers and for having “strong price transparency rules”.nnOn the other hand, Altarum recommended that Colorado create an oversight entity for healthcare spending and use claims data to address the provision of unnecessary care.nnThe report only evaluated policies in place before Dec. 31, 2019. Colorado plans to develop a state-regulated “public option” for health insurance scheduled to begin in 2022.nnThe most common healthcare burdens were the price of drugs and the cost of medical bills, and Colorado is one of the priciest states in healthcare spending per person. The Polis administration has stated that it would like to curb surprise medical bills from out-of-network providers, on which the report found 13 states had adopted full protections.nn“We intend to stop this practice of out-of-network surprise billing so that consumers aren’t asked to pay outrageous bills,” the administration wrote in its “Roadmap to Saving People Money on Healthcare.”nnOne policy that Altarum recommended for all states was to expand health insurance for undocumented immigrants, 45% of whom lack coverage. “Barriers to coverage cause significant hardship for these families and harm public health,” the report advised.nnOriginal article published on coloradopolitics.com
Jan 27, 2020 | Uncategorized
The New Year always brings opportunities to grow and learn. While many find it difficult to be healthy in the workplace there are simple steps to take to achieve a healthier lifestyle. Below are six great tips on building healthy habits at work. Read the article below to find out 6 ways you can build healthy habits at work and how these simple changes can be beneficial for you!nnnWe all know that we need to make healthier decisions on a daily basis, yet many of us fail to initiate substantial changes until health complications, stress, or other factors force us to take action.nnConvenience is one of the more common excuses. You’ll hear people say something like, “I work 50 hours a week and simply don’t have time to eat healthy, exercise, and care for my mental health.” Upon first hearing this, it’s easy to nod your head in agreement – but is this really a viable excuse? Does the fact that you work full-time excuse you from healthy living?nnIf we’re honest with ourselves, busyness is just a scapegoat for laziness. Millions of people hone healthy habits while at work and you can, too.nnHealthy workplace habits don’t form overnight. They command purposeful commitment and repetition. But if you’re going to prioritize health while working full-time, you’ll need to commit to habits like these:nn1. Packing Your Own LunchnnOne of the worst habits office workers have is poor nutrition. With limited time for lunch breaks and a desire to get out of the office, most people opt for fast food. And while fast-food meals are fine every couple of weeks, multiple greasy burgers each week will wreak havoc on your health.nnAs impractical as the suggestion may seem, try packing your own lunch and keeping it in the break room refrigerator. By meal prepping on Sundays, you give yourself access to healthy meals throughout the week (without having to do a bunch of cooking each day).nn2. Eating Healthy Office SnacksnnLunch isn’t the only thing that holds your diet back. If your office is like most, the only snacks you have available are highly processed vending machine selections. This has to change!nnTry explaining to your boss that healthy office snacks can boost productivity and output. If nothing else, they should replace the options in the vending machine. Better yet, try convincing management to put complimentary healthy snacks in the break room!nn3. Standing Up FrequentlynnSitting in front of your desk for seven or eight hours a day is awful for your posture, circulation, and overall health. While you probably don’t have many options for getting away from your desk, you can always switch up how you work.nnTry standing at your desk for at least 30-60 minutes per day. And instead of using a traditional office chair, look into a kneeling chair to improve posture and take some of the pressure off your neck and lower back.nn4. Getting 30 Minutes of Daily ExercisennIt’s highly recommended that you get at least 30 minutes of physical activity each day. If you’re unable to carve out time for a fitness routine before or after work, perhaps your lunch break will suffice.nnWhether it’s simple bodyweight exercises in your office or a full workout at a nearby gym, here are 10 lunchtime workouts that can be done in just half an hour. No excuses!nn5. Avoiding Negative SituationsnnToo much negativity will put a strain on your emotions and adversely impact your mental health. Thankfully, it’s often possible to avoid negative situations and surround yourself with positivity.nnOffice gossip and drama between coworkers should be things you avoid at all costs. If someone tries to pull you in, politely explain that you choose not to get caught up in office riffraff. Shielding yourself from this friction will keep you focused on work and productivity.nn6. Unplugging for Periods of TimennBeing constantly connected to the internet is exhausting. Though your job may require you to be dialed in for most of the day, look for brief periods where you can unplug and disconnect. Whether it’s a mid-morning break, your lunch break, or the commute to and from the office, cherish these opportunities to connect with your soul.nnPrioritizing Health in the WorkplacennNobody is going to prioritize your health for you. If it’s important to you, you have to be the one to proactively pursue smart behaviors that enhance your physical and mental capacities. If it helps, try rallying a few coworkers together and holding each other accountable. As they say, there’s power in numbers.nnOriginal article published on thriveglobal.com
Jan 22, 2020 | Uncategorized
Medicare, the Affordable Care Act, and other issues are all hot topics being discussed in 2020. Below is more information regarding some of the big topics that are in talks right now or are in the process of change. Read the article below for more information on some of these medical issues.nnnIt’s 2020 and another year of health-related topics awaits us. What health issues will take priority? What buzzwords will we all be talking about? How might technology change healthcare?nnWe asked some experts to peek into their crystal balls and make a few predictions.nnThey tell us that how you get access to healthcare and how you pay for it will both be hot topics this presidential election year.nnIn fact, one expert says healthcare could help decide political winners and losers.nn“Whoever comes up with a plan that will work, is affordable, and something people can understand, that will push them ahead,” said Kurt Mosley, vice president of strategic alliances for Merritt Hawkins, a physician search, consulting, and research firm.nnMedicarenMedicare is front and center as we kick-off 2020.nnThat’s in part because “Medicare for All” is the single-payer option health plan being touted by two of the top Democratic presidential candidates.nnJeff Becker, the senior analyst for healthcare strategy at Forrester Research says there are also a number of bills in Congress looking to expand access to Medicare as a public option.nn“When you look at the polling numbers, our call is that Medicare for All will die in the court of public opinion and become Medicare Advantage for more,” Becker told Healthline.nnAffordable Care ActnThe Affordable Care Act (ACA), often referred to as Obamacare, will be in the courts again this year.nnIn December, a federal appeals court ruled that the health insurance law’s individual mandate provision was unconstitutional.nnHowever, the justices sent back to a federal district court in Texas the issue of whether other parts of the law could continue to exist without the mandate that requires everyone to have health insurance.nnLook for some sort of Obamacare case to wind up in the U.S. Supreme Court this year.nn“Our call is whether or not it goes to the Supreme Court, the ACA will survive because the individual mandate is severable,” Becker told Healthline.nnPrice TransparencynExperts say you’ll hear a lot of debate about price transparency, a move designed to increase competition and lower costs.nnPresident Trump signed an executive order in November that requires hospitals and insurers to publish their confidential, negotiated rates for treatments.nn“The reason this would be important is you’d be able to figure out what your out-of-pocket expenses would be” said, Becker.nnBut a coalition of hospital groups has filed a lawsuit to block the rule. They argue that the public disclosure of negotiated charges would create confusion about consumers’ out-of-pocket costs.nnThe order is scheduled to go into effect on January 1, 2021.nnLower Prescription Drug Pricesn“The thing about pharmaceuticals is, if you can’t afford them, they don’t work,” Mosley said.nnHe predicts the move to lower the costs of prescription drugs will again be on the front burner of the healthcare debate in 2020.nn“The problem is Medicare and Medicaid can’t negotiate prices with these drug companies,” Mosley told Healthline.nnThe House of Representatives has approved a bill that would do just that. The legislation also caps out-of-pocket expenses for people enrolled in Medicare Part D.nnHowever, the prognosis for this bill becoming law isn’t good.nnPolitical observers say the legislation won’t go anywhere in the Senate, and the White House has indicated the president would veto it.nnRepublicans in the Senate have crafted their own prescription drug price plan. The president has indicated he would sign this bill, but it would need to be approved by the Democrat-controlled House.nnAccess to Health Servicesn“One of the cross-cutting issues we see as a priority in 2020 is the social determinants in health disparities in our patients,” said Amy Mullins, MD, FAAFP, medical director for quality improvement for the American Academy of Family Physicians.nn“Patients need more than just access to a physician,” she told Healthline. “They need access to good food, safe places to live, to exercise, transportation, community resources, access to medication.”nn“If you don’t address those, it’s really difficult to treat your patients effectively,” she added.nnMullins says her group has an internal division called the Center for Diversity and Health Equity whose mission is to look at healthcare through that lens.nnVaccine HesitancynMullins also says the issue of vaccine myths is one you’ll continue to hear about in 2020.nn“We want to do more to counter the misinformation that’s out there around vaccines that may be holding some people back from getting what they need,” said Mullins.nnA recent study concluded that a lot of the false information is being spread on social media by a handful of anti-vaccine ad buyers.nn“We’re promoting vaccine education to physicians, their healthcare teams, patients, and communities,” Mullins said.nnA 2020 National Vaccine Plan is currently being developed by the Department of Health and Human Services’ Office of Infectious Disease and HIV/AIDS Policy.nnVapingn“Another of the big priorities for health providers in 2020 is vaping and e-cigarettes, ” Mullins said.nn“We really applaud and support the work the Centers for Disease Control and Prevention and the Food and Drug Administration is doing to try and get a handle on this crisis,” she said. “But these products target adolescents and we think marketing needs more regulation.”nnA study released last month from the National Institute on Drug Abuse reported that more teens are vaping marijuana.nnThat’s despite a lung illness linked to vaping that’s killed more than 50 people trusted Source nationwide.nnVirtual care visitsnOn the digital front, Becker predicts there will be aggressive growth in virtual care visits.nnThat’s where you interact with your doctor via text, video, or phone call.nnBecker’s group crunched the numbers after looking at outpatient visit data as well as talking to virtual vendors and tracking healthcare investments.nn“The result was 36 million net new virtual care visits in 2020,” he said.nnHe points to how employers and insurers are already embracing the concept. Amazon recently launched a pilot program called “Amazon Care,” a virtual clinic for its employees in Seattle.nnWalmart recently expanded its telehealth services to workers in Colorado, Minnesota, and Wisconsin with $4 online or video care visits.nnHumana has teamed up with “Doctor on Demand” to offer a virtual primary care plan at significantly lower monthly premiums.nn“Everybody is moving toward a model where we’re not using high-cost care centers like emergency rooms,” Becker said.nn“And consumers are demanding more cost-effective services, too,” he added. “In 2018, consumers took out $88 billion in personal loans just to pay for out-of-pocket medical costs.”nnOriginal article published on healthline.com
Jan 22, 2020 | Uncategorized
Vaping and E-cigarette use by young adults has grown over the past few years. While many are ignoring the effects of using these products, the CDC and CMS have released addendums regarding these products after the World Health Organization confirmed the side effects of vapes and e-cigarettes. Read below for more on these important updates and what new codes will be used in conjunction with vaping-related disorders.nnWe have all seen the stories in the news lately about the effects vaping and e-cigarettes are having on young adults. The implications cannot be ignored and considering how quickly the World Health Organization (WHO) has responded it only confirms our suspicions.nnIn December, the CDC and CMS published the full addenda regarding the use of the new emergency U code for e-cigarette and vaping associated lung injuries (EVALI). This new code, U07.0 [Vaping-related disorder] is to be used in conjunction with other established ICD-10 codes for the reporting of medical encounters for EVALI.nnRefer to the links for the full releases by the CDC including CMS links to further information.n
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Jan 15, 2020 | Uncategorized
Anthem and Cigna have released updates regarding the reimbursement updates and changes. These changes will go into effect in March 2020. For more information on the updates and the changes that may affect you, read below!nnAnthem sent out a Notice of Material Change (NOMC), dated December 1st, 2019. This is notice of Anthem changing the reimbursement for Advanced Practitioners (NPs and PAs), effective March 1st, 2020. Moving forward, Anthem will no longer reimburse based on the “incident to” rules and Advanced Practitioners will be reimbursed at 85% of the contracted rate. This comes as a 15% decrease in reimbursement for Advanced Practitioners. This also means that any Advanced Practitioners that have not been added to Anthem’s system will need to submit new provider applications.nnAll provider files must be finalized by 03/01/20 for providers to be reimbursed. If submitting 10+ providers, Anthem has offered a roster format to expedite the process. If submitting less than 10 providers, each file will need to be submitted via Availity for processing. Anthem has assured Welter Healthcare Partners that provider files will move quickly when submitting via a roster and there should be no concern for the effective date. If there are fewer than 10 providers to be submitted, then individual new provider applications need to be submitted through Availity as soon as possible. Advanced Practitioners do not require full credentialing unless an NP would like to be listed as a PCP, so these files should be processed more quickly; however, we are within the 90-day timeframe.nnTo summarize, Anthem is essentially making three distinct and important changes that will affect your practice:n
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- Anthem will no longer recognize and reimburse based on the “Incident to” rule. This includes all services rendered by any eligible provider, even if the services meet Medicare guidelines.
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- Anthem is requiring all Advanced Practitioners (NPs and PAs) to be processed in their system, effective March 1st, 2020. Per Anthem, all Advanced Practitioners are eligible to submit claims directly to Anthem so new applications must be submitted if they are not loaded in the system.
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- All services rendered by Advanced Practitioners will be reimbursed at 85% of the applicable contract rate. This will come at a 15% decrease to your current contracted rate.
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nIf you need help or have additional questions regarding these reimbursement changes, please don’t hesitate to contact us!n
Jan 15, 2020 | Uncategorized
Last week, we briefly described the X modifier series and when to substitute these new modifiers. Below are a few scenarios from the NCCI policy manual you can refer to when using these modifiers.*n
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- The CCI bundle involving column 1 code 45385 (Flexible colonoscopy with removal of tumor[s], polyp[s], or lesion[s] by snare technique) and column 2 code 45380 (Flexible colonoscopy with single or multiple biopsies) with one of the four X modifiers. However, note the exact CCI guidance: “The use of modifier XS is only appropriate if the two procedures are performed on separate lesions. Use of modifier XE is only appropriate if the two procedures are performed at separate patient encounters. The documentation shall not be reported with a code for the same lesion”.
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- Generally, providers shall not report more than one physical medicine and rehabilitation therapy service for the same 15-minute time period. You’ll find that some CCI edits pair a timed CPT code with another timed, or non-timed, CPT. These edits can be bypassed “with modifier 59 or XU if the two procedures of a code pair edit are performed in different timed intervals even if sequential during the same patient encounter”.
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- The primary graft and skin substitute codes are mutually exclusive since only one type of graft or skin substitute can be used at a single anatomic site. If multiple sites require different types of grafts, use modifier XS to indicate the different sites.
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- You should not report HCPCS code J3471 (Injection, hyaluronidase, ovine, preservative-free, per 1 USP unit [up to 999 units]) with more than 999 units of service (UOS). If you report more than 999 units of the product described by J3471, you “may report HCPCS code J3471 on more than one line of a claim appending modifier XU to additional claim lines and should report no more than 999 UOS on any one claim line”.
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- You can report a diagnostic procedure in cases where the procedure’s findings necessitate a therapeutic response. “A diagnostic procedure is performed on a 60-year-old male complaining of chest pains. Due to the findings, a physician’s decision is then made to perform a therapeutic/surgical procedure. When the diagnostic cardiac angiography leads to a therapeutic angioplasty, use XU as the modifier.”
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n*As with all code reporting, be sure to check with individual payers on their policy regarding the X modifier series.
Jan 10, 2020 | Uncategorized
Welter Healthcare Partners is sharing the new 2020 CPT coding updates! Below you will find the new CPT codes that took effect on January 1st. Read below for more on these updates. Please note that this article is not an all-inclusive list of the updates. Be sure to review the CPT 2020 book for the complete descriptions of the changes.nnn2020 CPT Coding Updates nnWritten By: Ginger Avery, CPC, CPMA, CRC Coding & Compliance Manager nnIt’s that time of the year again! The new CPT®2020 code changes take effect January 1st and are based on input from clinicians, medical societies and the greater health care community. Understanding the myriad of upcoming changes is crucial to obtaining the proper reimbursement for your services! The changes for 2020 address a number of interrelated issues. Clinical practice and technology have evolved and several issues required much needed CPT expansion and clarification. CPT®2020 offers changes that affect nearly every specialty.nn*Please note, this article is not an all-inclusive list; review your CPT®2020 book for complete descriptions of all changes. Appendix B on page 816 of AMA’s CPT®2020 provides a summary of additions, deletions, and revisions. Watch for green text throughout the codebook for new information! nnThe American Medical Association’s (AMA’s) 2020 update of the CPT code set comprises 394 code changes, including 248 new codes, 71 deletions, and 75 revisions. Aside from anesthesia, all sections of CPT received changes in codes and guidelines.nnHighlights of the most significant changes are as follows: nnIntroduction Changes (see CPT®2020 pg xvi): n
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- Code Symbols update: “…even though the PLA section is located at the end of the pathology and laboratory section of the codes set, a PLA code does not fulfill Category I code criteria.”
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- Add-on Codes concept updated: “…when the add-on procedure can be reported bilaterally and is performed bilaterally, the appropriate add-on code is reported twice…Do not report modifier 50 in conjunction with add-on codes…See the definitions of modifier 50 and 51 in Appendix A.”
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nChanges to the Appendices (see CPT®2020 Pg 809) nnAppendix A: Modifiersn
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- Modifier 50: This modifier should not be appended to designated “add-on” codes (see Appendix D). If an additional or supplemental procedure is performed bilaterally, report the add-on code twice using the RT and LT modifiers to indicate laterality, rather than modifier 50.
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- Modifier 63: Should not be appended to any CPT codes listed in the Evaluation and Management Services, revised to include medicine section codes that can be reported.
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nAppendix E: CPT Codes Exempt from Modifier 51nnUpdated list of CPT codes exempt from modifier 51nnEvaluation and Management Changes (see CPT®2020 pg 38-56) n
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- Preventive
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- Do not report HBAI’s with Behavior Change Interventions
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- Non-Face-to-Face Services
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- Telephone Services (99441-99443)
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- Remote Physiologic Monitoring Treatment Management Services (99457-99458) was revised to be time-based.
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- E-visits: Six new CPT codes for reporting a range of digital health services including e-visits through secure patient portal messages.
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- Time-based codes 99421, 99422 and 99423 have been created to describe patient-initiated digital communications with a physician or other qualified health professional
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- 98970, 98971 and 98972 represent patient-initiated digital communications with a nonphysician health professional
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- New codes 99473 and 99474 allow reporting self-measured blood pressure monitoring (pg 42).
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- CPT 99473 is used to report patient education, setup, and device calibration.
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- To report 99474, a minimum of 12 recordings must be reviewed, and the provider must render an interpretation that includes average systolic and diastolic pressures and communication with the patient on the treatment plan.
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- Chronic Care Management (CCM) guideline update.
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- Transitional Care Management (TCM) guideline update.
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nSurgery Section Updates nnIntegumentaryn
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- The guidelines for intermediate and complex repairs (12031 – 13160) have been revised to provide a clearer description of what is required for undermining. Intermediate repairs include limited undermining, CPT describes as “a distance less than the maximum width of the defect, measured perpendicular to the closure line, along at least one entire edge of the defect.” Complex repairs include extensive undermining, CPT describes as “a distance greater than or equal to the maximum width of the defect, measured perpendicular to the closure line along at least one entire edge of the defect.”
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- New guidelines are also added in each of the subsections for breast procedures (19000 – 19303). An extensive review of these subsections is required. In addition, code 19304 is deleted due to low utilization. Parenthetical notes are added to direct you to the correct codes for this service.
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- New autologous grafting codes have been created. Code 15769 is reported for soft tissue harvested by direct excision. Codes for the harvesting of fat by liposuction are reported based on anatomic site and amount of fat removed. Harvesting codes are reported by the recipient site of the graft, not the donor site.
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- Codes 15771 and +15772 are reported for fat harvested via liposuction for defects of the trunk, breasts, scalp, arms, and/or legs. Code 15771 includes 50 ccs or less, and +15772 is an add-on code for each additional 50 ccs or part thereof.
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- Codes 15773 and +15774 are reported for fat harvested via liposuction for defects of the face, eyelids, mouth, neck, ears, orbits, genitalia, hands, and/or feet. Code 15773 includes 25 ccs or less, and +15774 is an add-on code for each additional 25 ccs or part thereof.
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- Codes for the excision for chest wall tumors (19260, 19271, 19272) are deleted and replaced with new codes in the Musculoskeletal System section (21601, 21602, 21603).
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nMusculoskeletal System nnNew codes have been created to report needle insertion into a muscle(s) without injection. Code 20560 is reported for one to two muscles, and 20561 is reported for three or more muscles.nnSix new add-on codes (20700-20705) are now available to report the manual preparation and insertion of drug delivery devices and the removal of the devices. The manual preparation includes the mixing of agents and placing them on the delivery device such as nails, beads, or spacers. Parenthetical notes are included to indicate the primary codes with which the add-on codes can be reported.nnRespiratory Nine nasal/sinus endoscopy codes (31233, 31235, 31292, 91293, 31294, 31295, 31296, 31297, and 31298) are revised. Parenthetical notes have been added for more consistent code descriptors and to clarify use.nnCardiovascular n
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- Codes for pericardiocentesis (33010, 33011, 33015) are deleted and replaced with new codes. Pericardiocentesis is no longer coded based on initial or subsequent service. There is now one code for pericardiocentesis (33016), which includes imaging guidance when performed; and there are three new pericardial drainage codes:n
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- 33017 is for pericardial drainage with the insertion of an indwelling catheter on patients 6 years and older. The procedure includes fluoroscopy or ultrasound guidance when performed.
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- 33018 is for pericardial drainage with the insertion of an indwelling catheter on patients 5 years old and under, or patients of any age with a cardiac anomaly. The procedure includes fluoroscopy or ultrasound guidance when performed.
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- 33019 is for pericardial drainage with the insertion of an indwelling catheter when computed tomography (CT) guidance is used. This code is not age-specific.
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- Ascending aorta graft code 33860 is deleted and replaced by two new codes: 33858 and 33859. When the procedure involves aortic dissection, use 33858. If performed for aortic disease other than dissection, use 33859.
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- The transverse arch graft code (33870) is deleted and replaced with 33871. The descriptor is revised to better describe the service as it is performed now.
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- Pacers or Implantable Defibrillators & device evaluation code instructions
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nDigestive System nnThe descriptors for internal hemorrhoidectomy codes 46945 and 46946 are revised to include “without imaging guidance.” Category III code 0249T is deleted and replaced with Category I code 46948 to report an internal hemorrhoidectomy by transanal hemorrhoidal dearterialization, which is a less invasive procedure than the traditional hemorrhoidectomy.nnNervous System nnInjection, Drainage or Aspiration updates (see codes 62270-62273 & 62328-62329)nnMedicine Section Changes nnNew influenza vaccine code (90694) to report a quadrivalent, inactivated, adjuvanted, preservative-free vaccine that is administered intramuscularly. See specific updates in CPT®2020 for the following bullets:n
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- Implantable, Insertable, and Wearable Cardiac Device Evaluations
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- New add-on code for myocardial strain imaging 93356
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- Cardiac Catheterizations (93451 – 93462)
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- Arterial & arterial-venous studies (93925-93990)
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- DIY Blood pressure monitoring (99473 – 99474)
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- Counseling/Risk Factor Reduction
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nUpdates for health and behavior assessment and intervention services: New codes 96156, 96158, 96164, 96167, and 96170, and add-on codes 96159, 96165, 96168, and 96171 for health and behavior assessment and intervention services will replace six older codes. According to the AMA, this update is intended to “more accurately reflect current clinical practice that increasingly emphasizes interdisciplinary care coordination and teamwork with physicians in primary care and specialty settings.”nnSignificant changes for reporting long-term electroencephalographic (EEG) monitoring services (95700-95726): Monitoring the electrical activity of the brain is critical to diagnose epilepsy. Four older codes have been deleted to make way for 23 new codes for long-term electroencephalographic (EEG) monitoring services. According to the AMA, the new codes provide better clarity around the services reported by a technologist, a physician, or another qualified health care provider.nnAs a reminder, with ALL services, the purpose of documentation is to tell an excellent story about each individual encounter. Why is the patient here today (what is the presenting problem), what are the observations, what is the clinical impression/plan of care? Focusing documentation on clinically relevant details for the unique services provided creates clear notes that help to support excellent patient care, creates clear collaboration between professionals and supports medical necessity for the services reported.nn Welter Healthcare Partners’s team of expert coders can help clinicians report the correct codes and ensure proper reimbursement for their services. We provide ongoing education and update our clients with changes to codes and reporting requirements, as well as provide documentation pointers to ensure clinician documentation is legible, complete, and accurate to help with timely reimbursement. Coding compliance plans, external audits, and annual clinician education is required by the ACA! Contact us today to get started!
Jan 10, 2020 | Uncategorized
It has been several years since CMS released the X modifier series, are you using these correctly or not at all? In an end of year survey, published in Part B News, 78% of respondents said they had reported an X modifier in 2019. The creation of the X modifier series is to report with greater specificity the scenarios when just 59 had been used in the past. Effective July 1, 2019, MAC’s now process modifier 59 when used on either column 1 or 2 codes in addition to the most appropriate X series modifier.nnHere is a great scenario for the use of XU [Unusual non-overlapping service]:nnIf a peripheral nerve block injection is performed for postoperative pain management on the same date as the anesthesia code used for the procedure, the use of modifiers XU is appended to the peripheral nerve block injection to indicate that it was used for the postoperative pain management.nnFor other great scenarios directly from CMS, click here. It has great detailed information about these modifiers and some additional scenarios to help.nnAnother great article on this topic was released in the December 30th issue of Part B News by Jim Dresbach, click here to read!
Jan 6, 2020 | Uncategorized
Welter Healthcare Partners is proud to have earned URAC accreditation for Credentials Verification Organization (CVO)! The designation demonstrates Welter Healthcare Partners is dedicated to quality and safety, and that we strive for continual improvement of the services we offer! Our URAC-accredited CVO meets the strict quality credentialing standards URAC’s other accreditation programs, ensuring healthcare organizations that the credentialing process is in compliance. URAC’s Credentials Verification Organization (CVO) Accreditation ensures a meaningful, rigorous, and fair credentialing process that protects both patients and providers from poor credentialing practices. Credentialing is a critical function that allows health care organizations to properly identify qualified health care practitioners for participation in their networks. The accreditation process is an important way to protect patients and to minimize legal exposure for health care organizations due to malpractice claims.nn“Increased scrutiny of healthcare quality makes credentials verification a vital component in delivering safe and successful care,” said URAC President and CEO Shawn Griffin, M.D. “ Welter Healthcare Partners is showcasing a commitment to quality by achieving Credentials Verification Organization Accreditation from URAC that’s designed to increase patient confidence, maintain provider excellence, and reduce legal exposure.”nnAbout URAC: URAC’s mission is to advance quality in healthcare through leadership, accreditation, measurement, and innovation. Founded in 1990, URAC is the independent leader in promoting healthcare quality through leadership, accreditation, measurement, and innovation. URAC is a nonprofit organization using evidence-based measures and developing standards through inclusive engagement with a range of stakeholders committed to improving the quality of healthcare. Our portfolio of accreditation and certification programs span the healthcare industry, addressing healthcare management, healthcare operations, health plans, pharmacies, telehealth providers, physician practices, and more. URAC accreditation is a symbol of excellence for organizations to showcase their validated commitment to quality and accountability.
Jan 6, 2020 | Uncategorized
The new year is a time for change, and many look at it as a time of reform. So as you make those resolutions to get back to the gym just remember that as we all get older, our bodies take longer to heal. Happy 2020!n
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- X50.0XX- Overexertion from strenuous movement or load [lifting heavy objects; lifting weights]
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- Y93.- Activity codes
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- Y93.A- Activities involving other cardiorespiratory exercises
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- Y93.B- Activities involving other muscle strengthening exercises
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- Y93.K1 Activity, walking an animal
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Dec 30, 2019 | Uncategorized
Welter Healthcare Partners would like to wish you a Happy New Year! As 2019 comes to a close, we are thrilled to see what 2020 has to offer. The past year has been a tremendous success, with the celebration of our 25th Anniversary and having fantastic clients to work with. nnWe wish you a happy, healthy and prosperous New Year!
Dec 23, 2019 | Uncategorized
The Welter Healthcare Partners Family would like to wish you a Happy Holidays! As we spend time with family and friends, we would like to say thank you to our awesome clients and those who support and appreciate the work that we do. In observance of the holiday, Welter Healthcare Partners will be closed on December 25th to spend the holidays with our loved ones. nnIt has been a wonderful year with all of you!
Dec 23, 2019 | Uncategorized
Seasons Greetings! The holidays are a time filled with love and laughter as we spend time with the ones closest to us. So while you’re out at family get together’s or running to the shops for the last-minute gifts here are a few codes to watch out for. Read below for some of the important codes to know!n
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- Y93.G – Activities involving food preparation, cooking and grilling
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- Y93.D – Activities involving arts and handcrafts
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- Z62.891 – Sibling rivalry
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- Z63.1 – Problems in relationship with in-laws
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- Z72.820 – Sleep deprivation
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- F43.8 – Emotional stress
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nJust to name a few. So stay safe and healthy this holiday season.
Dec 17, 2019 | Uncategorized
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The government funding deal that is set to pass this week will block President Trump from taking major actions against ObamaCare. There will also be some notable changes on the bill which include raising the minimum age to purchase tobacco to 21. There also some major wins for medical insurance companies. Read below to find out more information!nnThe government funding deal poised to pass Congress this week would block
President Trump from taking major actions to “sabotage” ObamaCare and would fully repeal three taxes in the health care law, according to a senior House Democratic aide.nnThe bipartisan deal would prevent Trump from taking what Democrats called “sabotage nuclear options” against ObamaCare. Specifically, that means the law will prevent Trump from unilaterally ending a workaround called “silver-loading,” which helps insurers compensate for the loss of key ObamaCare payments and has the effect of giving greater financial assistance to many ObamaCare enrollees.nnDemocrats had been worried Trump could end the practice in a bid to cause harm to the law. In addition, the deal will prevent Trump from ending automatic re-enrollment in ObamaCare plans, whereby if enrollees do not actively choose a new health insurance plan for the new year, they are automatically reenrolled to their current plan.nnOn a separate front on ObamaCare, the spending deal repeals three major taxes that had helped fund the law’s coverage expansion. The deal will repeal a 40 percent tax on generous “Cadillac” health plans, the 2.3 percent medical device tax and the health insurance tax.nnThose are major wins for the health insurance and medical device industries, which had long lobbied to lift those taxes. The Cadillac tax, in addition to providing about $200 billion in funding over 10 years, had been intended to help lower health care spending by incentivizing employers to lower costs to avoid hitting the tax. But the idea was opposed by unions and employers who did not want their health insurance plans taxed, setting up a broad bipartisan coalition against the idea.nnThe deal notably does not include a bipartisan measure to protect patients from surprise medical bills, despite a push from backers. That measure is mired in internal fighting among lawmakers and fierce lobbying by doctors and hospitals.nnThere are also not any major provisions included that would lower drug prices.nnHouse Democratic leaders are hoping there will be another chance to enact those priorities early next year, given that the deal sets up a May 22 deadline for renewing a range of expiring health programs like community health center funding. That deadline will create another must-pass health care bill that Democrats hope can include drug pricing and surprise billing measures.nnThe deal does include one relatively small bill to lower drug prices, called the Creates Act, which cracks down on drug companies gaming the system to delay the introduction of cheaper generic competitors.nnThe measure also raises the legal age to purchase tobacco to 21.nnDrug pricing advocates had fought for years to pass the bill, which was long opposed by the pharmaceutical industry. It is a sign of at least a small shift in the drug pricing debate that the measure is now passing.nn
nOriginal article published on thehill.comnn
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Dec 17, 2019 | Uncategorized
As we approach 2020, we are gearing up for the changes that are making headway the coming year. Below are some of the updates that have been released regarding E/M changes, the final rule, and the physician fee schedule. For more information read below. For more on the services Welter Healthcare Partners provides contact us at 303.534.0388, or click here!nnWhat’s New for 2020 nnThe CY 2020 PFS conversion factor will increase to $36.0896, up to $0.05 from CY 2019. nnThree new Telehealth Service codes added to the Medicare-covered services list: n
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- G2086 (Office‐based treatment for opioid use disorder, including the development of the treatment plan, care coordination, individual therapy, and group therapy and counseling; at least 70 minutes in the first calendar month)
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- n
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- G2087 (Office‐based treatment for opioid use disorder, including care coordination, individual therapy, and group therapy and counseling; at least 60 minutes in a subsequent calendar month).
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- G2088 (Office‐based treatment for opioid use disorder, including care coordination, individual therapy, and group therapy and counseling; each additional 30 minutes beyond the first 120 minutes).
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nCMS will offer these services without the usual geographical limitations for telehealth. The Medicare telehealth originating site fee increased to $26.65 in 2020, from $26.15 in 2019.nnPrincipal Care Management (PCM) for Chronic Care Management (CCM) nnIf you provide chronic care management (CCM) to patients with one chronic condition next year, report code G2064 for 30 minutes of work by a doctor or other qualified health care professional: “Comprehensive care management services for a single high‐risk disease, e.g., principal care management, at least 30 minutes of physician or other qualified health care professional time per calendar month with the following elements: One complex chronic condition lasting at least three months, which is the focus of the care plan, the condition is of sufficient severity to place patient at risk of hospitalization or have been the cause of a recent hospitalization, the condition requires development or revision of disease‐specific care plan, the condition requires frequent adjustments in the medication regimen, and/or the management of the condition is unusually complex due to comorbidities.” When clinical staff performs the work, you will report G2065.nnReduction of Administrative Burden nnModifications to the documentation policy now allows physicians, physician assistants, and advanced practice registered nurses (APRNs – nurse practitioners, clinical nurse specialists, certified nurse‐midwives and certified registered nurse anesthetists) to review and verify (sign and date), rather than re‐documenting, notes made in the medical record by other physicians, residents, medical, physician assistant, and APRN students, nurses, or other members of the medical team. CMS also defined the APRN group of providers, which includes nurse practitioners, clinical nurse specialists, certified nurse‐midwives and certified registered nurse anesthetists.nnPhysician Assistants Make Ground n
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- CMS’ finalized its proposal to adjust the authority of physician assistants (PA): Allowing them to practice without specific assignment to an M.D., requiring only “documentation in the medical record of the PA’s approach to working with physicians”. o Requires that in states where the PA’s scope of practice is not specified, the PA’s “working relationship” with the practice’s physicians must be documented “at the practice level.”
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- CMS cautiously approved its proposal to allow certified registered nurse anesthetists (CRNAs) to do pre‐anesthesia assessments on patients, as well as post‐anesthesia assessments without the supervision of an M.D. CMS, clarifies that “a physician must examine the patient to evaluate the risk of the procedure to be performed,” while either “a physician or anesthetist must examine the patient to evaluate the risk of anesthesia.”
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nCMS Final Rule Aligns with E/M Coding Changes Laid Out by the CPT Editorial Panel for Office/Outpatient E/M Visits Beginning in 2021 n
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- Reduce the number of levels to 4 for office/outpatient E/M visits for new patients (99202‐99205);
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- Retain all 5 levels of coding for established patients (99211‐99215);
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- Revision of time‐based reporting and medical decision‐making process for all office‐based E/M codes; performance of history and exam only as medically appropriate (complexity will be more clearly defined);
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- E/M visit level selected based on either medical decision making or time.
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- CMS also finalized the relative value units (RVU) for the group of oft‐used E/M services, which will determine 2021 pay rates. The RVU changes, for example, would boost payments for code 99214 – the most‐reported E/M code – from $109 to $136 per claim, a 25% increase. Rates for 99213 would jump nearly 30%.
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nFor more information on these updates visit pbn.decisionhealth.com, ama-assn.org, cms.gov, and aafp.orgnn nn nn
