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Believe it or not, 2013 is just about half over. That means it‘«÷s time to assess your fiscal year and see what you want to do to finish the year with the best possible bottom line.

I know it‘«÷s difficult to find time in the midst of a busy practice, but this is something you don‘«÷t want to skip. Here are a few items you need to review:

1. Are you ready for the eRX incentives/penalty? Now is the time to qualify for eRx incentives and avoid the 2% Medicare penalty that will start in 2014. June 30 is the end of the 6-month reporting period for 2013 to avoid the 2014 adjustment‘«Űgiving you only 7 more business days. To prevent the adjustment to your Medicare payments, you have to submit 10 G codes by June 30 and they must be processed into the National Claims History by July 26.

2. Have you made a decision on how your practice will handle PQRS reporting? As we mentioned in a previous blog post, while the PQRS will remain voluntary, starting with the 2013 reporting year, it will include both incentives for 2013 (+0.5%) and penalties for non-participation in 2015 (-1.5%).?Š 2015 penalties may also be avoided by electing to participate in the ‘«£administrative claims-based reporting mechanism‘«ō by October 15, 2013.?ŠRead More

3. Have you reviewed your denial rates and reasons for this year? As expert Elizabeth Woodcock, MBA, FACMPE, CPC, advises, you should develop a systematic process for managing and tracking denials so you can monitor them by type, frequency and payer to reveal new opportunities to make your collections process more efficient. The midpoint of the year is an excellent time to do this, so that you can make sure your denials are reduced and managed effectively for the remainder of the year.

4. How is your ICD-10 plan coming along? If you haven‘«÷t developed a plan for implementing ICD-10, stop waiting. In an interview with Healthcare IT News, Farzad Mostashari, MD, national coordinator for health information technology, said his best advice for providers is to begin prepping for the change now. If you haven‘«÷t already, now is the time to begin assessing the impact on your practice and your training needs. Find more information in our recent blog posts and white paper.

5. Have you evaluated ways to generate additional revenue this year? In our recent blog post entitled ‘«£Healthcare Providers: There are Ways to Make More Money,‘«ō we offered some ideas on how to identify additional revenue in your practice. Make sure you‘«÷re not missing out on some low-hanging fruit this year.

6. Finally, have you evaluated your medical billing to determine if you have the right team for your practice needs now? Sometimes a practice outgrows an inhouse or one-person billing company, and doesn‘«÷t realize it. The mid-year point is a good time to review your revenue cycle to see if you‘«÷re getting paid as quickly as you should, whether your denial rate is as low as it could be, and whether your appeals are being handled effectively.

If you find that your medical billing needs have changed and you are looking for a new solution, or if you would just like to explore how your bottom line could be improved, contact at 800-966-9270. We‘«÷re ready to help you evaluate your options for revenue cycle management.

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Medical Billing Resource CenterHave questions on how to prepare for ICD-10?

Wonder how your practice denial rate and collection rates compare with other practices?

Whether you need some help with improving your bottom line or getting started with ICD-10, we can now offer you an online resource center to help. Our Resource Center is now open, featuring:

White papers on improving your bottom line, how to evaluate medical billing services, ICD-10 and more

– All issues of our monthly enewsletter, Monitor, filled with medical billing and coding news and tips

Infographics including our popular infographic on avoiding CMS penalties for eRX & PQRS

– A Practice Revenue Analysis Tool that will help you compare your results to industry standards

– And of course, links to this blog

We‘«÷ve had many requests for these useful tools, so we wanted to gather them in one place where they‘«÷d be easy to access. They‘«÷re now available to you 24/7, to help bring more to your medical practice bottom line.

Take a moment now to review the Resource Center and tell us what you‘«÷d like us to add. We want this Resource Center to meet your medical billing and coding needs.

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The Coding Institute
Here are some excellent tips from a leading resource for coding training and information.

CMS Clarifies 99495 and 99496 Use: Answers to Place and Date of Service Questions

CMS offered some new insights into how Medicare payers expect you to use 2013‘«÷s new transitional care management (TCM) codes during the agency‘«÷s March 12 Open Door Forum, noting several important points about the TCM codes to keep in mind when completing your claims.

The new TCM codes are:

99495, Transitional care management services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge, medical decision-making of at least moderate complexity during the service period, and face-to-face visit within 14 calendar days of discharge

99496, Transitional care management services?Š with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within two business days of discharge, medical decision-making of high complexity during the service period, and face-to- face visit within seven calendar days of discharge.

The codes are intended to apply when a physician oversees a patient whose health issues necessitate moderate to high complexity medical decision making (MDM) during the shift from a healthcare facility setting back to the patient‘«÷s community (home) setting.

‘«£A face-to-face visit is required within a specific time frame after the patient‘«÷s discharge, depending on which code you‘«÷re reporting,‘«ō said David A. Ellington, MD, an AMA CPT?ę Editorial Panel member who presented E/M changes at the CPT?ę and RBRVS 2013 Annual Symposium ( ‘«£The initial interactive contact ‘«Ų face-to-face, phone call, or email ‘«Ų should be within two business days of discharge. If you make two attempts to contact the patient or caregiver within that time but are unsuccessful, CPT?ę states that you can still report transitional services if the other criteria are met.‘«ō

Additional Pointers
During the March 12 CMS forum, CMS‘«÷ Ryan Howe emphasized the following areas:

– When determining which place of service (POS) code to use on your TCM claim, you should use the location that ‘«£required the face-to-face visit.‘«ō

– The 30-day TCM period begins on the date of discharge and continues for the next 29 days. Your date of service should be the thirtieth day of care‘«Ų not the first, Howe said during the CMS call.

– CMS will reject any claims with dates of service prior to Jan. 30, 2013, because the codes became effective on Jan. 1 and only cover 30-day periods.

– You can report TCM codes for both new and established patients, Howe said, which is a departure from CPT?ę rules. ‘«£CPT?ę guidance suggests that the codes are only for established patients, but for Medicare purposes, they can be reported for new patients as well,‘«ō he said.

– If 30 days pass between discharge and the initial communication with the TCM practitioner, you cannot report TCM codes, Howe said during the call.

– Medicare will pay only the first TCM claim received per beneficiary in one 30-day period beginning on the date of discharge, so if more than one practitioner reports the code for the same patient, only the doctor whose claim is received first will get paid.

– If the patient dies before the thirtieth day of TCM, you cannot report the TCM codes because they cover a full 30 days. Instead, you‘«÷d report the appropriate E/M code.

For more on the TCM codes, read the FAQs at


Reduce ‘«£Ordering/Referring‘«ō Edit Losses with These Quick Steps

Key: Double check physician NPI is individual and not group practice NPI.

If you have been postponing updating your ordering/referring physician info, take action or you may have begun seeing losses starting in May.

Phase 2 of the ‘«£ordering/referring‘«ō edits hit May 1 and CMS indicated they would issue costly denials as opposed to less burdensome returned claims when practices have invalid ordering/referring physician information. The system will deny claims when the doctor isn‘«÷t in the Provider Enrollment, Chain, and Ownership System (PECOS) file or when the name doesn‘«÷t match.

Smart practices will take these six steps to minimize cash flow delays and financial losses due to ‘«£ordering/referring‘«ō edit denials:

1. Check and recheck. CMS posts a ‘«£Medicare Ordering and Referring File‘«ō on its website with the full list of ‘«£the National Provider Identifier (NPI) and legal name (last name, first name) of all physicians and non-physician practitioners who are of a type/specialty that is legally eligible to order and refer in the Medicare program and who have current enrollment records in Medicare (i.e., they have enrollment records in PECOS),‘«ō CMS explains on the site. The website is at CMS updates the report weekly, it says in newly?Šrevised MLN Matters article SE1305.

Now is the time to step up PECOS file checking. Pay attention to which physicians are sending referrals and ordering services and verify that those physicians are eligible to do so and are currently enrolled in PECOS.

2. Spur enrollment. If you find your docs don‘«÷t have a record in PECOS, you‘«÷ll need to get them to enroll in it or you won‘«÷t be able to get paid.

Resource: Links to educational Medicare articles about enrolling in PECOS are in the ‘«£Additional Information‘«ō section at the end of the MLN Matters article at

3. Match the PECOS file exactly. If your claim calls a physician ‘«£Jack‘«ō and he‘«÷s listed as ‘«£John‘«ō in the PECOS file, it will get shot down. Also, don‘«÷t use credentials such as ‘«£Dr.‘«ō in the name field, CMS advises.

Key: On paper claims, be sure to list first name first and last name last in item 17.

Don‘«÷t let software differences trigger unnecessary edits. Make sure that the physician information that is on file in the providers‘«÷ software systems and is being coded on the claim for enrolled physicians matches the PECOS information, including both the NPI and physician name.

4. Use the right NPI. ‘«£Ensure that the name and the NPI you enter for the Ordering/Referring Provider belong to an individual physician or non-physician practitioner and not to an organization, such as a group practice that employs the physician or non-physician practitioner who generated the order or referral,‘«ō CMS instructs.

5. Know the rules for exceptions. Use the teaching physician‘«÷s information for interns and residents, CMS directs. The exception is for docs in states that license their residents. State-licensed residents may enroll in PECOS on their own to order and/or refer and may be listed on claims.


Separate Problem Can Be Billed During a Well Check Visit

When a patient comes to your office for a preventive wellness visit, if the patient mentions a health problem or other concern during the preventive visit, the encounter might qualify for two codes.

Checkpoint: If the problem ranks as ‘«£significant,‘«ō you can report your work to address it in addition to the preventive care. This may take the form of a problem- oriented E/M code (e.g. 99201-99215), a procedural service, or both.

Key: Although poorly covered in the past, many payers now recognize and pay for these separate, significantly identifiable services addressed during preventive medicine visits. Of course, those additional services, if covered, may also result in a patient financial obligation (e.g. deductible, copay, or coinsurance) that would not accrue with a simple preventive visit. ?ŠManaging patient expectations in this situation is important.

3 Tips: If you‘«÷re still unsure whether you‘«÷re justified in billing a problem- based E/M code along with the preventive visit, keep a few criteria in mind:

1. If the problem is significant enough that it would require or justify the patient to come back for another visit if the internal medicine physician doesn‘«÷t address it, that could be a clue that you‘«÷re dealing with a problem-based E/M situation.

2. Check whether the problem has its own ICD-9 diagnosis code. If so, that means addressing the issue could be a stand-alone (and separately reportable) service.

3. Look for additional evaluation and treatment options, such as X-ray or lab tests, or written prescriptions. These can be other signs that the physician is addressing a significant problem.


Penalties Could Be Coming Your Way for Illegible Documentation

If your physician‘«÷s handwriting is really difficult to read, you should be worried–because payers are getting stricter about illegible documentation and he may face penalties, advises The Coding Institute.

Physicians could actually have problems with payers in the future if the payers cannot read their notes. Billers should stress the importance of legible notes to their providers and may even want to suggest that they print, use dictation, or invest in an electronic medical record (EMR) system to ensure legibility.

Many coders shake their heads when they hear that some physicians maintain incomplete notes, and that auditors ask those physicians for money back since their documentation didn‘«÷t support the codes they billed. But have you ever thought that writing illegibly could make you qualify for CMS‘«÷s interpretation of incomplete notes?

‘«£When determining the medical necessity of an item or service billed, Medicare‘«÷s review contractors must rely on the medical documentation submitted by the provider in support of a given claim,‘«ō CMS says in MLN Matters article SE1237. ‘«£Therefore, legibility of clinical notes and other supporting documentation is critical to avoid Medicare FFS [fee-for-service] claim payment denials.‘«ō

To read the MLN Matters article, visit

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This month we have a number of useful articles on coding that will help you avoid errors and code more precisely.

The G-Codes Are Here for Payment Claims – Ready Or Not
Effective July 1, the Centers for Medicare & Medicaid Services will begin rejecting claims received for Medicare Part B patients that do not include the new requirement of G-coding.

G-coding is a claims-based coding system that CMS plans to “collect and analyze”?ō the data to better understand patient outcomes. It also is meant to be used towards the various conversations surrounding the healthcare reform options floating around…?ŠRead More

CMS Releases Clarification on Reporting External Cause Codes and Unspecified Codes
On May 17, 2013, the Centers for Medicare & Medicaid Services (CMS) released several important clarifications in their ICD-10 Industry Update email. There has been some confusion and frustration regarding the codes in Chapter 20, External Causes of Morbidity (V, W, X, and Y codes), which will replace the current ICD-9-CM E-Code section. Read More

In Sync With ICD-10
In the race to prepare for the new codes, will providers and payers be able to successfully cross the finish line together?

It’s been said that a chain is only as strong as its weakest link. As the timeline for the health care industry’s mammoth ICD-10 implementation marches forward, industry professionals are becoming increasingly aware that if all stakeholders are not ready for the October 1, 2014, deadline, calamity could ensue.

“Everyone is wondering about everyone else…”?ō Read More

2013 OIG Work Plan: HHS Targets Three Areas
From a coding perspective, mechanical ventilation, cancelled surgeries, and Medicare’s transfer policy take top billing.

Last October, the Office of Inspector General (OIG) released its work plan for fiscal year (FY) 2013, an event that sometimes can trigger anxiety among health care organizations. Published annually, the work plan outlines the OIG’s enforcement priorities, enabling health care facilities to better identify compliance risks and more accurately gauge their chances of meeting the requirements…?ŠRead More

Coding for Acute Coronary Syndrome
Acute coronary syndrome (ACS) is classified to ICD-9-CM code 411.1, which is the same code assigned for unstable angina. It is vital to review the entire medical record to make sure the information presented supports the final code assignment. Therefore, if the record contains evidence that the patient may have experienced an AMI but only ACS is documented, then it may be appropriate to query the physician for clarification of the final diagnosis. Final code assignment always is based on physician documentation…?ŠRead More

Dual Coding: An ICD-10 Jump-Starter?Š
By adopting this tactic, health care organizations can accelerate the transition process.

There has been a palpable shift in the conversation surrounding the transition to ICD-10. No longer is it focused on whether the Centers for Medicare & Medicaid Services (CMS) will extend the deadline yet again (it won’t). Instead, it centers on just how soon organizations should start coding in ICD-10 to minimize operational and financial impacts once the October 1, 2014, deadline hits.

For early adopters, the opportunity to code in a dual ICD-9/ICD-10 environment can generate benefits that outweigh negatives such as productivity declines and revenue cycle slowdowns…?ŠRead More

Read Between the Lines: Saving Your Physicians from Copy-and-Paste Problems
Identifying harmful copy-and-paste documentation can help curb serious coding errors.

Like any good story, a medical record should be consistent and relatively easy for the reader to follow, presenting events in a logical sequence. However, as physicians begin to document in the EHR, the patient’s story–the crucial element necessary for coding–can become jumbled and sometimes even unreadable. Coders may begin to see nonsequential dates on progress notes…?ŠRead More

The Coding Corner: Avoid Common Place-of-Service Coding Errors
Place of Service (POS) codes identify where a health care service is provided, which directly affects payment. As explained in MLN Matters?ę Number: SE1104, “To account for the increased practice expense that physicians generally incur by performing services in their offices and other non-facility locations, Medicare reimburses physicians at a higher rate for certain services…?ŠRead More

Appending Modifiers 58, 78, and 79
Modifiers identify procedures that have been altered in some way without changing the fundamental components. In this article, we will examine the modifiers that can be appended to procedure codes for services performed within the global period…?ŠRead More

Updated Codes for Claims Adjustment, Remittance Advice Under HIPAA Released
The Council for Affordable and Quality Healthcare has released updated code combinations for its CORE 360 rule, which is a part of the operating rules for electronic transfer of healthcare funds and remittance advice under HIPAA, according to an AHA News Now report…?ŠRead More

HCPCS Update: Prepare for Medicare’s July Coverage Changes to Zometa and Doxil Codes
Add 2 new Q codes to your system to keep your coding compliant.

The July 2013 HCPCS update has coding changes in store for both liposomal doxorubicin HCl and zoledronic acid. Pay attention both to the new codes available and the coverage changes Medicare will make to existing codes…?ŠRead More

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Is your practice ready for the influx of patients expected with the launch of healthcare insurance exchanges mandated by ACA for Jan. 1, 2014??ŠFourteen million U.S. residents will join the ranks of the newly insured on Jan. 1, 2014, according to the Congressional Budget Office.

‘«£Definitely!‘«ō you might think‘«Ų‘«£I‘«÷m ready for more revenue.‘«ō

Yes, but what about your practice: your staff and your processes? Are they ready?

Right now your office probably chugs along fairly well (or maybe not‘«Ųyou decide). But if the volume of patients you‘«÷re seeing increases rapidly, what will happen to your systems?

– Will no shows go through the roof because staff doesn‘«÷t have time to make reminder calls?

– Will patients wait interminably because check-in isn‘«÷t smooth (and meanwhile, your Yelp ratings plummet)?

– Will you be seeing patients whose coverage isn‘«÷t confirmed because staff didn‘«÷t have time to verify eligibility? (And not everyone will be covered, in spite of the mandate.)

– Will your denial rates rise and your appeal success drop because billing staff are simply overwhelmed?

These are all possibilities‘«Ųif you don‘«÷t review your office processes now, tighten up where needed and plan ahead for the increase.

Here are some steps you should take now:

1. Do an audit of your office. Where are the bottlenecks? How can they be eliminated?

2. Verify eligibility electronically. If you‘«÷re not already verifying eligibility electronically, there will never be a better time to make that change. You can‘«÷t afford having staff spend hours on the phone or even an hour visiting different insurers‘«÷ websites‘«Ųthey need a one-stop method of checking. Many billing software solutions offer this now, and your staff will need it.

3. Take patient histories electronically. By taking patient histories electronically via a patient portal or a tablet in the office, you‘«÷ll reduce wait times for patients (a major source of dissatisfaction) and eliminate the need for a staff member to enter the data into the EHR. This is vital with an increased patient flow; if you have patients sitting, filling in patient histories by hand, your scheduling is going to be shot within the first 2 hours. And you know many of them will forget to fill in the patient history ahead of time or forget to bring it if they do fill it in.

4. Use electronic check-in. Either through a patient portal or in-office kiosks, you need to have patients check themselves in. This will save your front office staff a great deal of time and reduce waiting time. It also offers patients the opportunity to cancel and reschedule easily in advance‘«Ųwhich means you won‘«÷t have holes in your schedule you have to juggle at the last minute.

5. Evaluate your billing processes. With more patients to bill and file claims for, your billing staff could easily be overwhelmed. Then think about the denial management and appeals‘«Ųwill your staff be able to handle the increased volume? Plus get ready for ICD-10?

Even if your billing staff is able to handle the volume of billing your practice currently sees, with the increased number of patients, they may soon be overwhelmed. Plus, they may be seeing new types of denials and problems as payers sort out how they‘«÷ll handle the new coverage.

That‘«÷s why now may be the time to consider turning to a medical billing service‘«Ųan organization that will be up to speed on all of the new regulations and requirements, able to staff up quickly and handle the increase in claim volume. This is what a medical billing service‘«Ųparticularly a nationwide medical billing service like‘«Ųdoes every day.

Find out how we can insure that your medical billing runs smoothly‘«Ųand brings more to your bottom line‘«Ųeven in the face of changes such as the health insurance exchanges and ICD-10.

We‘«÷re ready; we‘«÷ll make sure you‘«÷re ready.

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Medical practice profitability survey reveals less than 9% of physicians are very confident in their medical billing.Two very interesting pieces of news caught my eye this week, and the implications for medical practices from each of these pieces of news is rather staggering, in my opinion.

1. A survey on physician profitability just released by social learning and collaboration platform ?ŠQuantiaMD and EHR/PMS company CareCloud found that only 9% of physicians are ‘«£very confident‘«ō in their current staff, tech and processes for getting paid.

2. A recent blog post on Healthcare IT News discussed the fact that payers are changing their systems from a ‘«£pay-and-chase‘«ō post-payment recovery model to efforts to prevent overpayments. ‘«£Some are implementing analytical technologies to identify possible claim discrepancies at the time a claim is adjudicated. These tools combine predictive, data-driven, integrated code edits and clinical aberrancy rules to identify claim outliers. Unlike rules-based systems, data-driven analytical solutions examine hundreds of variables, and can detect previously unknown and emerging patterns that rules-based analytics may not recognize,‘«ō the article says.

The article goes on to say that ‘«£An additional layer that can deliver savings to a multi-faceted payment integrity program is to reduce billing overpayments that result from improper coding. This can be achieved by supplementing analytics with clinical code edit technologies backed by nationally recognized coding guidelines as they are designed to find coding errors, unbundled treatments, unusual and inconsistent treatment patterns, and inappropriate diagnoses.‘«ō

What these two pieces of news mean to me is that while 91% of physicians are less than ‘«£very confident‘«ō about their billing processes, they are about to face increased scrutiny from payers with finely tuned analytics software, which means that every coding error, unbundled treatment, unusual and inconsistent treatment pattern and inappropriate diagnosis could cause their claim reimbursements to, at best, be delayed, and at worst, to be denied.

This is a recipe for disaster for many practices.

In addition, when asked in the survey how much of their time was spent on ‘«£coding, documentation and administration,‘«ō rather than patient care, the majority of physicians?Š(59%)?Šsaid they sacrificed more than?Š(20%)?Šof their time this way. This is the equivalent of one day per week for a full-time physician spent at a desk rather than in an exam room. About?Š(30%)?Šof physicians spend one-third of their time ‘«Ű or more ‘«Ű on administrative tasks.

So what this picture reveals is that physicians are spending way more time than they want to‘«Ųor should‘«Ųtrying to oversee billing processes they were never trained to manage, with staff who have varying levels of training and experience.

No wonder 91% of them are less than ‘«£very confident‘«ō about their billing‘«ŲI‘«÷m sure an even higher percentage are less than ‘«£very happy‘«ō about this situation!

Plus, a key finding of the PPI survey was that the 5,012 physician participants were two-thirds more likely to foresee a downward trend in profitability for the year ahead than a positive one (36% negative vs. 22% positive). That means it‘«÷s even more hazardous to have billing processes that they‘«÷re not confident in‘«Ųthey need every dollar they can get on the bottom line.

Add all of this together, and it becomes more clear than ever that now is the time for medical practices to change their approach to billing and entrust it to trained professionals who have the technology, processes and experience to handle the current requirements and challenges that lie ahead.

Medical billing is an exceptionally complicated and convoluted process, and only becoming more so. Why would you want less than expert help to manage the lifeblood of your practice?

Find out today how you can have full confidence in your billing processes and bring more to your bottom line. Contact at 800-966-9270 for a complimentary review of your billing.

“Medical Billing made all the difference for my practice. They eliminated all the frustrations associated with insurance reimbursements and increased my revenues by 100%.” ?Š–Janice

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Review these articles from a variety of sources to insure your coding is up to date on E/M, LCD, and other techniques.

Wolves at the Door: E/M Coding Now

Barbara Aubry, a regulatory analyst for 3M Health Information Systems, reports that in the last few weeks, she has read some startling news:

1. The University of Illinois Hospital and Health Sciences System and Mount Sinai Hospital in Chicago owe CMS $145 million in disproportionate share Medicaid overpayments “because they had overcharged poor patients,” according to a FierceHealthFinance news report Feb. 27. What’s even more startling is the alleged overcharges took place 13 years ago.

2. Another stunning article reported Feb. 14 by HealthLeaders Media discussed the case of a respected surgeon who was found guilty of fraudulent coding on claims submitted between August 2002 and October 2003. The doctor was “acquitted of two counts of Medicare fraud but convicted of two counts of making false statements in connection with surgical (CPT) codes submitted” on old claims. He is now serving a 10-month prison sentence.

The Association of American Physicians and Surgeons (AAPS) warns, according to the article, “physicians will now need to practice ‘defensive documentation,’ taking more time away from patient care in order to double and triple check operative notes.” Barbara prefers to call it clinical documentation improvement (CDI), but agrees with the AAPS: Documentation is more important than ever. Read More


Modifier Minute: Modifier 32

Modifier 32?ŠMandated services?Šapplies when a third party, such as an insurer or government agency, specifically requests/requires a service on a patient‘«÷s behalf. For instance‘«™ Read More


Follow New CMS Guidelines ?Što Keep Record Amendments Updated

No practice ‘«Ű or physician ‘«Ű is immune to documentation that needs to be updated; maybe the physician left out an important piece of information, such as the amount of time spent counseling the patient, or the patient‘«÷s diagnosis. When records need to be amended, advises The Coding Institute, be sure your practice follows the latest CMS rules, which were revised on Dec. 7, 2012, in Transmittal 442.

When adding, correcting, or entering information after the date of service, you should identify it as an amendment, and the physician should sign and date it. Never delete the original entry‘«Ųinstead, ensure that all original content is identifiable. You can do this on a paper record by using a single strike line through the original content. For electronic records, you must ‘«£provide a reliable means to clearly identify the original content, the modified content, and the date of authorship of each modification of the record,‘«ō CMS says in the transmittal.

If an auditor ever reviews your files, CMS directs them to consider your amended entries‘«Ųbut only if you follow the rules. Auditors ‘«£shall not consider undated or unsigned entries handwritten in the margin of the document,‘«ō for instance, the Transmittal advises.

CMS advises MACs and auditors that see potential fraud in the documentation to refer those cases to the ZPIC auditors. To read the complete transmittal, visit


CMS corrects edit 84, deletes modifiers reports in an April 30 article that CMS corrected edit 84, added five APCs to the I/OCE, deleted two APCs, and changed the description of another as part of the April updates to the I/OCE. In addition, CMS deleted all of the genetic testing modifiers, retroactive to January 1‘«™ Read More


Denials Management: With MUE Claim Denials, Appeal, and Appeal Again
If you receive a claim denial due to MUEs, you can appeal, according to a recent article by The Coding Institute.

You should follow three steps during the appeals process:

Step 1: Determine the reason for the denial. First, figure out if you made a coding or billing error. If you find a coding error

‘«Ų?Š?Š?Š such as the wrong number of units entered in the units box

‘«Ų?Š submit a corrected claim. If you don‘«÷t find a coding or billing error, move on to the next step.

Step 2: Decide if you have a legitimate reason to appeal. If you believe there is medical necessity for the services over and above the allowable under the MUE, you should appeal to the contractor. ‘«£If there is no medical necessity, take a look

again at coding,‘«ō Harrington says. ‘«£Make sure service is coded properly, and appropriate modifiers have been assigned.‘«ō

Step 3: Appeal the claim. File an initial appeal with your carrier and follow the standard five-level Medicare appeals process. ‘«£If appealing the claim due to a clinical reason, you may wish to employ clinical expertise when putting together your appeal letter,‘«ō Harrington suggests.


Healthcare News: CMS Adds Codes to Conditionally Bilateral List

Also from CMS added seven CPT codes to the conditionally bilateral list as part of the April update to the Integrated Outpatient Code Editor. When a provider performs a conditionally bilateral service bilaterally, coders must append modifier -50 (bilateral procedure) to the code. Read More


Local Coverage Determinations Provide the Missing Link to Complement Coding Guidelines

The missing link to correct coding, according to an article in, is coder knowledge and practical application of Local Coverage Determinations (LCDs). LCDs are integral to complete documentation governing accurate ICD-9 diagnoses coding. LCDs in essence complement official coding guidelines and Coding Clinic advice. Few coding staff actually know and apply?Šofficial LCDs in their region to complement official coding guidelines and policies. Read More


Observation Services: Many Shades of Gray

This recent article in For the Record states that unique challenges give hospitals and physicians little room for error when it comes to correctly documenting these encounters. According to Betsy Nicoletti, MS, CPC, coauthor of, one complicating factor is that while a hospital ultimately determines the category of a patient‘«÷s admission status, the rules are clear that a patient‘«÷s observation stay begins and ends with a physician‘«÷s order‘«™ Read More

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Last week we looked at how to write an effective appeals letter, but obviously there‘«÷s much more to the process. To review how to effectively manage your appeals process, we‘«÷ll turn to two experts in the field: Elizabeth W. Woodcock, MBA, FACMPE, CPC, and Nancy Clark, CPC, CPC-I.

Practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC, offered ‘«£A Dozen Steps to Successfully Appeal Denied Claims‘«ō in this article, including these tips:

Recognize denials. The key is to identify it as separate and distinct from a contractual adjustment, which is ‘«Ű and should be ‘«Ű a write off.

– Don‘«÷t procrastinate. There is often a timeframe in which you can resubmit a claim after it‘«÷s been denied.

– Make a compelling case. Among the tips Woodcock provides here are: Develop a professional letter that begins by referencing the claim number, date of service and patient; then, briefly describe the particulars of the service in question; use the insurer‘«÷s own language if possible; look to see if Medicare or Medicaid pays for the service; if they do, you can argue that even the government has determined that payment is appropriate; Copy and attach sections that support your case from coding manuals, including past issues of the American Medical Association (AMA) CPT Coding Assistant.

– Confirm receipt. Don‘«÷t just send the appeal and hope for the best, Woodcock advises. Review your submission online, or call the insurance company to confirm that they received your appeal, noting the name of the operator, extension number, date and time. Follow up in 30 days.

– Set boundaries and don‘«÷t go overboard. Establish protocols for dollar thresholds that you‘«÷ll appeal only once, twice, etc. Avoid fighting for a claim that should have never been submitted in the first place, such as an undocumented service.

– Carbon copy stakeholders. Your appeal to reverse a denial is a matter between you and the insurance company, but sometimes pulling in other key stakeholders helps. Your first, and most important, advocate is the patient.

– Maintain a hassle folder for each insurance company and develop supportive language in your contract. It pays to maintain a record of reimbursements and denials in order to effectively review your contract for its strategic contribution to the practice‘«÷s bottom line. Proactively negotiate the inclusion of language that supports your efforts to appeal claims.

– Compile appeals. Appealing claims one-by-one may get the results you need, but it is laborious. If you‘«÷ve seen the same service denied for the same reason multiple times, compile your appeals and present them together for reconsideration.

Read the full article at

In a separate article, The Real Deal About Appeals, Part 1, expert Nancy Clark, CPC, CPC-I, offers additional useful advice, including:

– Clarify the reason for the denial. For example, is the service not covered because it is deemed medically unnecessary? Is this procedure specifically excluded from the patient‘«÷s benefits contract? Did the insurance carrier not recognize a modifier or modifiers on the claim?

– When the cause of denial has been clearly identified, ask what documentation you need to appeal the claim. For example, they may request operative notes and pathology reports.

– Confirm the insurance carrier‘«÷s formal appeal process. This may require using a form provided by the company or it may require a written appeal on the practice‘«÷s letterhead. Some commercial carriers and Medicare Administrative Contractors (MACs) have a standardized form available on their websites, while some carriers may prefer the use of a form from the state‘«÷s department of banking and insurance.

– Obtain the specific address to which the claim should be mailed. Include the name of the department or person to whose attention it should be addressed. If possible, get a fax number. This may yield faster results.

– Document the phone call, the representative‘«÷s name, and the date of the conversation. Keep this information in the appeal file.

Read the full article at

Be sure to prepare for battle when you‘«÷re appealing claims by having a plan, doing your homework, and writing an effective appeals letter.

When you need assistance with your appeals, contact at 800-966-9270. allocates over 50% of its billing costs to the successful collection of the last 20-30% of charges that typically do not get paid on first submission. We can help you get paid for the tough claims your staff doesn‘«÷t have time to pursue.

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Are the results from your appeals as good as you‘«÷d like them to be? If not, you should check out the advice from leading experts in the industry. They have practical recommendations on process, how to write a strong appeal letter, knowing when to appeal, and more.

Our first resource is an excellent article in For the Record magazine, The Art of the Appeal Letter
by Lindsey Getz. The author interviewed several experts, who provided these tips on writing a successful appeal letter:

1. Before putting pen to paper, review the claim for hints about why it was rejected.

2. Include documentation of exactly what took place, including the clinical outcome. The goal is to show that you followed procedure.

3. Gather all documentation prior to starting the writing process.

4. Be sure to include the necessary info: Any good appeal letter requires a few basic necessities, including the background information/scenario, the issue at hand, the request to return to the initial Medicare-severity diagnosis-related group (MS-DRG), and a detailed explanation regarding the request.

5. Remember that there are three basic types of appeals: medical necessity, administrative, and coding, each of which requires a unique approach.

Medical Necessity Appeal
In this situation, denials typically are focused on short stays. When writing the appeal, focus on engaging the reader. Jacqueline E. Poliseno, RN, BSN, CPHM, a case management manager at Craneware, says this can be accomplished by ‘«£telling the story‘«ō behind the appeal. Don‘«÷t scrimp on the details, she says, and be sure to include the following points when pertinent:

– What did the patient look like at the time of presentation?

– What treatment did the patient receive in the emergency department?

– What symptoms remained after treatment?

– What treatment was intended for the admission?

– What happened each day of the stay? (Talk specifically about what the patient looked like clinically and the treatments/services provided.)

‘«£Then end your story with discharge information,‘«ō she advises.

Administrative Appeal
In the event of a weak clinical argument, it may be wise to write an administrative appeal focused on the physician‘«÷s intent to admit the patient as an inpatient. Highlight the principles articulated in the Medicare Benefit Policy Manual that provide Medicare‘«÷s definition of an inpatient.

Coding Appeal
These denials typically are related to documentation, Poliseno says, adding that the arrival of ICD-10 will have no effect on the process. No matter if it‘«÷s ICD-9 or ICD-10, writing an effective coding appeal letter requires the author to have extensive coding knowledge. Like the other appeal processes, gathering the appropriate support materials is essential.

Managing Appeals
Poliseno says organizations must have a system in place that allows them to track and monitor denials and appeals. This will help ensure that appeal letters go out in a timely manner to meet payer deadlines.

‘«£You have to assess what you already have in queue, asking ‘«ˇHow old is it?‘«÷ and ‘«ˇHow small is it?‘«÷‘«ō Nesbitt says. ‘«£These are the questions that will help you determine if it‘«÷s truly worth pursuing.

Read the complete article at

Next week, we‘«÷ll share tips from practice management expert Elizabeth W. Woodcock, MBA, FACMPE, CPC.

And if you need assistance with your appeals, contact at 800-966-9270. allocates over 50% of its billing costs to the successful collection of the last 20-30% of charges that typically do not get paid on first submission. These are the claims your staff probably doesn‘«÷t have either the time or expertise to collect on‘«Ųbut we do, and we do it every day.

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Medicare will begin enforcing a new claim denial process on May 1 that will affect multiple health care providers ordering particular Medicare-covered items or services for Medicare beneficiaries. As of that date, a provider of a covered clinical laboratory, imaging, durable medical equipment, prosthetics, orthotics and supplies (DMEPOS) or home health service will not be paid if the ordering or certifying practitioner has not enrolled in Medicare or properly opted out.

The final rule was issued on June 26, 2012 after Medicare officials modified the proposed regulations in several ways in response to advocacy from healthcare provider associations. CMS states that:

‘«£Effective May 1, 2013, the Centers for Medicare & Medicaid Services (CMS) will turn on the Phase 2 denial edits. This means that Medicare will deny claims for services or supplies that require an ordering/referring provider to be identified and that provider is not identified, is not in Medicare’s enrollment records, or is not of a specialty type that may order/refer the service/item being billed.‘«ō

Phase 1 edits notified providers if the ordering or certifying practitioner was not enrolled or properly opted out but did not deny payment. The CMS uses the term “ordering/referring” to refer to practitioners who order or certify covered items and services. PECOS is the Internet-based Provider Enrollment, Chain and Ownership System.

What this means to you

In Phase 2, if the ordering/referring provider does not pass the edits, the claim will be denied. This means that the billing provider will not be paid for the items or services that were furnished based on the order or referral. Below are the denial edits for Part B providers and suppliers who submit claims to carriers and/or MACs, including DMEMACs:

254D Referring/Ordering Provider Not Allowed To Refer

255D Referring/Ordering Provider Mismatch

289D Referring/Ordering Provider NPI Required

CARC code 16 and/or the RARC code N264 and N265 shall be used for denied or adjusted claims.

The announcement of Phase 2 implementation in a special edition of MLN Matters?Šincludes guidance and Q&A on the new rule:

I order and refer. How will I know if I need to take any sort of action with respect to these two edits?

In order for the claim from the billing provider (the provider who furnished the item or service) to be paid by Medicare for furnishing the item or service that you ordered or referred, you, the ordering/referring provider, need to ensure that:

a. You have a current Medicare enrollment record.

‘«ů If you are not sure you are enrolled in Medicare, you may:

i. Check the Ordering Referring Report and if you are on that report, you have a current enrollment record in Medicare and it contains your NPI;

ii. Contact your designated Medicare enrollment contractor and ask if you have an enrollment record in Medicare and it contains the NPI; or

iii. Use Internet-based PECOS to look for your Medicare enrollment record (if no record is displayed, you do not have an enrollment record in Medicare).

iv. If you choose iii, please read the information on the Medicare provider/supplier enrollment web page about Internet-based PECOS before you begin.

b. If you do not have an enrollment record in Medicare.

‘«ů You need to submit either an electronic application through the use of internet-based PECOS or a paper enrollment application to Medicare.

c. You are an opt-out physician and would like to order and refer services. What should you do?

If you are a physician who has opted out of Medicare, you may order items or services for Medicare beneficiaries by submitting an opt-out affidavit to a Medicare contractor within your specific jurisdiction. Your opt-out information must be current (an affidavit must be completed every 2 years, and the NPI is required on the affidavit).

d. You are of a type/specialty that can order or refer items or services for Medicare beneficiaries.

When you enrolled in Medicare, you indicated your Medicare specialty. Any physician specialty (Chiropractors are excluded) and only the non-physician practitioner specialties listed above in this article are eligible to order or refer in the Medicare program.

Be sure to review MLN Matters for full information on the rule.

For help in ensuring you are receiving all the reimbursement your practice deserves, contact at 800-966-9270 or is a national medical billing company with 5 locations (and growing) on the East coast and West coast alike. We do billing for over 1,500 providers. We are headquartered in Los Angeles, with large billing centers in Manhattan, Long Island, Los Angeles, Maine and Atlanta.

We‘«÷re ready to help you bring all the revenue you deserve to your bottom line.

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