Billing & Coding Updates

Update:   August 10, 2016

CMS:  MACRA (Medicare Access & CHIP Reauthorization Act of 2015)

MACRA will bring three important changes to how Medicare pays those who provide care to Medicare beneficiaries.  The changes create a Quality Payment Program (QPP).  The three changes are: Ending the Sustainable Growth Rate, making a new framework for rewarding health care providers for providing better care, and combining CMS’ existing quality report programs into one new system.  There are two paths under the MACRA Quality Payment Program.  These are:  The Merit-Based Incentive Payment System (MIPS) and the Alternative Payment Models (APM).   At this time these changes are proposed and it is expected that MIPS and APMs will go into effect January 1, 2017.  For more information visit CMS’ website.



Update:   March 31, 2016

October 1, 2016 Brings New ICD-10 Codes

CMS along with the Centers for Disease Control and Prevention (CDC) are adding new ICD-10 codes effective October 1, 2016.   There will be 1,943 new diagnosis codes added.

Source:  CMS



Update:   June 25, 2015

Medicare conversion factor set to increase July 1

The Centers for Medicare & Medicaid Services (CMS) has released the updated RVU files that reflect the new conversion factor which increases from $35.7547 to $35.9335 effective July 1, 2015. Read more….



Update: November 10, 2014

PQRS Negative Payment Adjustment

On Monday, November 10, CMS began sending letters to eligible professionals (EPs), including group practices, subject to the 2015 Physician Quality Reporting System (PQRS) negative payment adjustment. Beginning on January 1, 2015, CMS will apply a negative PQRS payment adjustment of 1.5 percent to payments under the Medicare Physician Fee Schedule for individual EPs and group practices who did not meet the criteria for satisfactory reporting in the PQRS for the applicable reporting period.

The PQRS is part of the effort to transform the health care delivery system by linking Medicare reimbursements to the quality of care delivered to Medicare beneficiaries. In order to do this, individual EPs and group practices are required to participate in reporting quality metrics in order to help CMS evaluate the quality of care they deliver. Those that do not participate in one of the quality reporting initiatives will see a negative payment adjustment beginning in 2015.



Update:  October 31, 2014

Units Reporting on Claims

The number of units is the number of services performed and reported per service line as defined in the CPT code description.

Report one unit for all services without a measure in the description or that have a measure range (eg. 1-15 lesions, First 20 cm, First 10 sq. cm). Some procedures that fall in this category may be repeated and reported on separate lines with appropriate modifiers (eg. Lesion removal, x-rays, labs).

Report the number of units as the number of services performed for services with a measure in the description. Key terms to watch for: each, each additional, per, or drug measurements.



Coding E/M Visits Based on Time

When billing E/M visits based upon “time”, there needs to be clear documentation of the total time the provider spent face-to-face with the patient and how much of that time was spent on counseling/coordination of care.   An Example of correct documentation for billing based on time is:

“A total of __ minutes were spent face-to-face with the patient during today’s visit. Of that time, __ minutes (over half of that time) were spent on counseling/coordination of care pertaining to ___ issue(s).”


Modifiers Can Affect Payment Rates

Modifiers help to provide a more accurate picture of what specifically was done for a patient by the provider/clinic/facility that you are billing for. Some of these modifiers may affect the payment amount. The common modifiers that affect payment amounts are 22, 26, 50, 52, 53, 54, 55, 56, 62, 66, 73, 74, 80, 81, 82, AS, BL, FB, FC, GA, GZ, PA, PB, PC, SL, TC. The amount payments are affected vary by payer. Check your payer contracts for the specific amounts that payments may be affected.

Posted by :  Kaleidoscope, Deni Adams, CPC