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Cerumen Removal

Coding Cerumen Removal


The CPT® guidelines states “for cerumen removal that is not impacted, see E/M service code” such new or established office patient (99201-99215), subsequent hospital care (99231-99233), etc. which means if the earwax isn’t impacted, removal is not separately billed and is included in the documented E/M service reported.

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Care and Safety of Medicare and Medicaid Patients

CMS to improve care and safety of Medicare and Medicaid patients

The Centers for Medicare & Medicaid Services (CMS) issued a final rule to help improve the care and safety of Medicare and Medicaid patients, covering approximately 1.5 million patients in over 15,000 long-term care facilities.

Care and Safety of Medicare & Medicaid patients

Last year, CMS began offering consumers and families the ability to easily compare facilities based on successful discharges, unplanned emergency visits, and re-hospitalizations through a five-star website. However, the rules of the road for long-term care facilities haven’t had a comprehensive update since 1991.

According to a CMS Press Release, the changes finalized in the rule include:

  • Strengthening the rights of long-term care facility residents, including prohibiting the use of pre-dispute binding arbitration agreements.
  • Ensuring that long-term care facility staff members are properly trained on caring for residents with dementia and in preventing elder abuse.
  • Ensuring that long-term care facilities take into consideration the health of residents when making decisions on the kinds and levels of staffing a facility needs to properly take care of its residents.
  • Ensuring staff members have the right skill sets and competencies to provide person-centered care to residents. The care plans developed for residents will take into consideration their goals of care and preferences.
  • Improving care planning, including discharge planning for all residents with involvement of the facility’s interdisciplinary team and consideration of the caregiver’s capacity, giving residents information they need for follow-up after discharge, and ensuring that instructions are transmitted to any receiving facilities or services.
  • Allowing dietitians and therapy providers the authority to write orders in their areas of expertise when a physician delegates the responsibility and state licensing laws allow.
  • Updating the long-term care facility’s infection prevention and control program, including requiring an infection prevention and control officer and an antibiotic stewardship program that includes antibiotic use protocols and a system to monitor antibiotic use.

These changes are part of CMS’s goal of making healthcare “more person-centered” for Medicare and Medicaid beneficiaries and their family members. The care and safety of Medicare & Medicaid patients are a key point to CMS’s goal of the person-centered healthcare.


Alternative Payment Models (APMs)

Alternative Payment Models (APMs) incentive participation

The Centers for Medicare & Medicaid Services (CMS) issued a final rule describing how Medicare will incorporates quality measurement into payments, and how it will incentivize participation in Alternative Payment Models (APMs).
In accordance with the Medicare Access and CHIP Reauthorization Act (MACRA) regulation of 2015, CMS created the Quality Payment Program (QPP), and proposed in April 2016 how it intends to pay healthcare providers in the near future through an Advanced APM or through the Merit-based Incentive Payment System (MIPS).

Final Rule vs. Proposed Rule
For the most part, today’s rule finalizes everything CMS proposed in April, with a few twists that are intended to make the transition to the new quality-based payment program easier for healthcare providers.
According to CMS, the changes in today’s final rule will:
• Support small and independent practices by creating a transition year and a learning and development period in the beginning of the program;
• Strengthen the movement towards Advanced APMs by offering potential new opportunities;
• Secure a strong start to the program with a flexible, pick-your-own-pace approach to the initial years of the program; and
• Connect the statutory domains into one unified program that supports clinician-driven quality improvement.
2017 and, likely, 2018 will be transition years, in which MIPS eligible clinicians can choose one of four options to submit data:
Option 1: Report to MIPS for a full 90-day period. CMS recommends MIPS eligible clinicians to report for a full year because it will improve their chances to qualify for a positive adjustment.
Option 2: Report to MIPS for a minimum 90-day period and report more than one quality measure, more than one improvement activity, or more than the required measures in the Advancing Care Information performance category.
Option 3: Report one Quality measure; one activity in the Improvement Activities category; or report the required measures of the Advancing Care Information category. Choosing to not report even one measure or activity will result in a MIPS eligible clinician receiving the full negative 4 percent adjustment, warns CMS.
Option 4: Participate in an Advanced APM. If you receive a sufficient portion of your Medicare payments or see a sufficient portion of your Medicare patients through an advanced APM, you will qualify for a 5 percent bonus incentive payment in 2019.
“We envision that it will take a few years to reach a steady state in the program, and we therefore anticipate a ramp-up process and gradual transition with less financial risk for clinicians in at least the first 2 years,” CMS states in the final rule.
Initially, many small practices will be excluded from MIPS due to the low-volume threshold, which has been set at less than or equal to $30,000 (up from $10,000 in proposed rule) in Medicare Part B allowed charges, or less than or equal to 100 Medicare patients.

New CPT influenza Virus Vaccine Code

CPT influenza Virus Vaccine Code, 90674 will be paid by Medicare starting 1/3/2017

90674 is the latest in series of Flu Codes. The Centers for Medicare & Medicaid Services (CMS) announced in a recent transmittal, Medicare will pay for the newest CPT influenza virus vaccine, 90674. Payments won’t begin until January 3, 2017, as 2017 codes won’t go into effect until after the first of the year. However, claims with dates of services on or after August 1, 2016 will be covered.

CPT influenza Virus Vaccine

CPT 90674 defined as, Influenza virus Vaccine, quadrivalent (ccIIV4), derived from cell cultures, sub-unit preservative and antibiotic free, 0.5 mL dosage, for intramuscular use is the latest in influenza codes added to the code set. The code is out of numerical sequence in the CPT book and is sequenced after CPT \90661.

The transmittal instructs Medicare administrative contractors to manually add the code with an effective date of service of August 1, 2016 with Type of Service V. v. MACs will pay for influenza virus vaccine code 90674 based on the lower of the actual charge or 95 percent of the Average Wholesale Price (AWP) to:

• Indian Health Services (IHS) hospitals submitting claims on TOB 12X and 13X
• IHS CAHs submitting claims on TOB 85X
• Comprehensive Outpatient Rehabilitation Facilities using TOB 75X
• Independent Renal Dialysis Facilities using TOB 72X

According to MLN Matters, number MM9763 MACs will hold institutional claims with code 90674 with dates of service on or after January 1, 2017, through February 20, 2017, until the Fiscal Intermediary Shared System (FISS) changes are implemented on February 20, 2017.
As usual, Medicare will use the CMS Season Influenza Pricing webpage to determine the payment rate for 90674.
Medicare will issue further instructions on how to handle claims for code 90674 with dates of service from August 1, 2017, through December 31, 2016.

It should be noted by coders that 90764 only pays for the vaccine product. Use codes 90460, 90464, 90471, 90472, 90473, and 90474 to report the administration of a vaccine. The evaluation and management (E/M) code should be reported separately, if appropriate.

SSN to be replaced with MBI by CMS

SSN to be replaced with MBI by CMS

SSN to be replaced with MBI! Now we have even more acronyms for us to remember!

  • SSN = Social Security Number,
  • MBI = Medicare Beneficiary Identifier,
  • CMS = Centers for Medicare & Medicaid Services,
  • MACRA = Medicare Access and CHIP Re-authorization Act of 2015,
  • HICN = Health Insurance Claim Number,
  • SSA= Social Security Administration,
  • RRB = United States Railroad Retirement Board


MACRA is an acronym for the Medicare Access and CHIP Re-authorization Act of 2015, legislation that brought about physician payment reform and inspired the Centers for Medicare & Medicaid Services’ (CMS’) Quality Payment Program. And that SSN is an abbreviation for Social Security Number that controls our lives, and our livelihood. The Medicare Access and CHIP Re-authorization Act (MACRA) of 2015, requires us to remove Social Security Numbers (SSNs) from all Medicare cards by April 2019. A new randomly generated Medicare Beneficiary Identifier (MBI) will replace the SSN based Health Insurance Claim Number (HICN) on the new Medicare cards for Medicare transactions like billing, eligibility status, and claim status.

We currently use an SSN-based HICN to identify people with Medicare and administer the program.

  • The Social Security Administration (SSA)
  • The United States Railroad Retirement Board (RRB)
  • State Medicaid Agencies
  • Health care providers
  • Health plans


MBI stands for Medicare Beneficiary Identifier, a term born from MACRA and the Social Security Number Removal Initiative (SSNRI).

MACRA requires CMS to replace SSN based Health Insurance Claim Numbers (HICNs) for MBIs on all Medicare cards by April 2019. The MBIs, which will consist of 11 randomly-generated characters (numbers and uppercase letters), will be used for Medicare transactions such as billing, eligibility status, and claim status.

As with SSNs, each MBI is confidential and providers will need to safeguard these numbers, just as they do all protected health information.

CMS says it will begin issuing new cards featuring MBIs in April 2018, and Medicare beneficiaries may begin using them upon receipt. To allow providers and insurers time to update their systems to accommodate the new format, CMS will accept either HICNs or MBIs for data exchange between April 1, 2018 and Dec. 31, 2019.

TB screening updates

TB screening updates


The U.S. Preventive Services Task Force (USPSTF) released in September a final recommendation statement on TB screening for latent tuberculosis infection (LTBI) in adults.

The USPSTF recommends screening among adults who are at increased risk of tuberculosis, but who do not have symptoms. This recommendation does not apply to adults with symptoms of tuberculosis or to children and adolescents. The independent, volunteer panel of national health experts has given this recommendation a grade B, meaning it is highly certain screening offers a moderate benefit, or moderately certain screening offers a moderate-to-substantial benefit.

This recommendation is in line with the recommendations of others. The CDC identifies persons at risk for developing tuberculosis as those who have an increased likelihood of exposure to persons with tuberculosis disease, or persons with clinical conditions or other factors associated with an increased risk of progression from LTBI to tuberculosis disease (HIV infection, injection drug use, radiographic evidence of prior healed tuberculosis, low body weight, or other medical conditions).

Although Latent Tuberculosis(LTBI) is asymptomatic, signs and symptoms of active tuberculosis disease may include cough (R05), hemoptysis (R04.2), abnormal weight loss (R63.4), night sweats (R61), fever (R50.9), and shortness of breath (R06.02). Note that signs or symptoms routinely associated with tuberculosis should not be assigned in addition to a confirmed diagnosis of the disease (ICD-10 category A15 – A19).


Two types of screening tests for LTBI are currently available in the United States:

  • Mantoux tuberculin skin test (TST) (CPT® 86580Skin text; tuberculosis, intradermal)
  • Interferon-gamma release assays (IGRAs) (CPT® 86480Tuberculosis test, cell medicated immunity antigen response measurement; gamma interferon)


The skin test reaction is measured in millimeters of the “induration” after 48 to 72 hours.

IGRAs require a single blood sample and laboratory processing within 8 to 30 hours after collection. Two types of IGRAs are currently approved by the FDA:

  • T-SPOT.TB (Oxford Immunotec Global)
  • QuantiFERON-TB Gold In-Tube (Qiagen)


Generally, the CDC recommends screening with either the TST or IGRA, but not both.

The USPSTF found no evidence on the optimal frequency of screening for LTBI. Depending on specific risk factors, screening frequency could range from one time only screening among persons who are at low risk for future tuberculosis exposure, to annual screening among those who are at continued risk of exposure.

Undercoding Problems

Undercoding can definitely be a problem


When it comes to audit results, most compliance experts, providers, and coders worry about “overcoding,” or reporting a service or procedure not sufficiently supported by documentation. Although overcoding is definitely a problem that doesn’t mean you’re making the right choice to “play it safe” by deliberately undercoding, or reporting a lower-level service than is supported by documentation.




Undercoding also affects patients negatively, and skews the data that Medicare and other payers use to calculate payments, going forward:

Under coding misrepresents the true level care that is provided to Medicare beneficiaries. These statistics are used to calculate future Medicare payments and track trends in healthcare delivery. Patterns of under coding may be viewed as aberrant and open your practice up to audits and reviews. In addition, under coding impacts your practice revenue. You are not being appropriately paid for the level of service you provide to your patients. Correcting under coded claims means costly appeals.


Undercoding is no way to assure compliance in fact, it is, itself, a compliance risk. Rather, practices should strive to report services at the level supported by provider documentation, or “right coding.”“When one practices right coding, coding the level of service supported by your documentation, will win patients and the Medicare program.”

Ventilator Code Changes

Ventilator code changes

Ventilator technology has advanced in recent years, with the latest rage being a single device capable of treating multiple conditions. In one mode, it’s a continuous positive airway pressure (CPAP) device; in another mode, it’s a respiratory assist device (RAD); and in yet another mode, it’s a traditional ventilator device. Prescribing it for your patients may get you accused of Medicare abuse.
According to an Office of Inspector General (OIG) September 2016 Data Brief, “suppliers could bill Medicare for the device as if it were being used as a ventilator, when use of a lower-cost CPAP device or RAD is indicated based on the patient’s medical condition.”
Medicare claims for noninvasive pressure support ventilators grew 85 times, and diagnoses shifted from neuromuscular conditions to respiratory conditions, according to the OIG report between 2009 and 2015.The rental rates for HCPCS Level II code E0464 Pressure support ventilator with volume control mode used with noninvasive interface (i.e., mask) were as much as $660, $1,470, and $1,352 more per month, respectively, than the rates for volume ventilators, CPAP devices, and RADs during the review period. These monthly rental payments for ventilators continue indefinitely, whereas those for CPAP devices and RADs are capped at 13 months.
Also between 2009 and 2015, E0464 claims listing a neuromuscular disease diagnosis decreased from 56 percent to 7 percent. Meanwhile, diagnoses of chronic respiratory failure increased from 29 percent in 2009 to 85 percent in 2015.
Respiratory Assist Devices are covered for beneficiaries with less severe conditions that require only relatively short durations of respiratory support; ventilators are covered for more severe conditions; and CPAP devices are covered for the treatment of obstructive sleep apnea.
This year, the Centers for Medicare & Medicaid Services (CMS) consolidated ventilator codes and reduced the reimbursement amount for noninvasive pressure support ventilators.
Effective January 1, 2016, added codes are:

• E0465 Home ventilator, any type, used with invasive interface, (e.g., tracheostomy tube)
• E0466 Home ventilator, any type, used with non-invasive interface, (e.g., mask, chest shell)
• And deleted codes are: E0450, E0460, E0461, E0463, and E0464.
• Codes E0450 and E0463 crosswalk to E0465 and codes E0460, E4061, and E0464 crosswalk to E0466.

These changes are unlikely to resolve inappropriate billing, so be prepared for medical review of ventilator claims.
Signs of inappropriate billing for ventilators include:
• Patients being prescribed multiple devices concurrently.
• Separate billing for accessories, indicating unbundling.
• Diagnosis doesn’t support medical necessity of billed device.

Double Dip

What is considered a “double dip” or “double dipping” ?

Double Dip “Don’t”  – The first use of double dip means to bill twice for the same item; for instance, by separately reporting a service that is included in another (already claimed) procedure. Such unbundling is prohibited, and—even if done unintentionally—can quickly land you in hot water with payers. This type of double dipping is never OK.

Nothing in either the 1995 or 1997 E/M documentation guidelines state that you cannot count a single documented item in both the history and review of systems (ROS)—so called “double dipping.” Nothing in AMA/CPT® or Centers for Medicare & Medicaid (CMS) guidelines says so, either.

double dip

If an item is clearly documented, you may count it in both the history and ROS. Repetition of data is not required, as long as it is appropriately referred to.
You cannot use a single documented item twice within the same component of the E/M service. In other words, you shouldn’t use the same statement twice within the history or within the ROS.
If a patient shows up with only one complaint, do not use that single complaint for both the history and ROS. Rather, you should look for documented evidence that the provider looked deeper, to find more information to assist him or her in identifying what is wrong with the patient and how to treat it.
The bottom line is, if the physician looks beyond the presenting problem, performing additional work to expand on the problem identified in the chief complaint and HPI, you may “double dip” and count a single element in both the history and ROS. Doing so is not only legitimate, it may mean the difference between, For example, a level III and a Level IV E/M code assignment.

Medicare Advantage and Part D

CMS on moving Medicare Advantage and Part D forward

Since passage of the Affordable Care Act, both Medicare Advantage and the Part D prescription drug programs have continued to grow, while premium growth has been low and quality has improved. Medicare Advantage and Part D will continue to provide greater protections for beneficiaries and value for taxpayers, thanks to the successful implementation of the Affordable Care Act’s reforms.

Medicare Advantage and Part D
The data released with the 2017 plan landscape indicate that from when the Affordable Care Act was enacted in 2010 through 2017:
• Medicare Advantage average monthly premiums is projected to fall by 13 percent.
• Medicare Advantage enrollment will have increased by more than 60 percent to an all-time high of 18.5 million Medicare beneficiaries. In 2017, this will represent about 32 percent of Medicare beneficiaries.
Many other indicators demonstrate that the Medicare Advantage program remains strong:
• Access to the Medicare Advantage program remains nearly universal, with 99 percent of Medicare beneficiaries having access to a health plan in their area.
• The average number of Medicare Advantage plan choices per county is approximately unchanged from 2016, and access to supplemental benefits, such as dental and vision benefits, continues to grow.
• Over 94 percent of Medicare beneficiaries have access to a $0 premium Medicare Advantage plan.
• 100 percent of Medicare beneficiaries including Medicare Advantage enrollees have access to recommended Medicare-covered preventive services at zero cost sharing.
Medicare has taken other steps to strengthen the Medicare Advantage program that include:
• Allowing Medicare beneficiaries a one-time opportunity to switch to a 5-star Medicare Advantage plan or prescription drug plan in their area any time during the year.
• Continuing the inclusion of a low performing icon on ( so beneficiaries know which plans are not performing well.
• Implementing the Affordable Care Act requirement that all Medicare Advantage plan sponsors spend at least 85 percent of premiums on quality and care delivery and not on overhead, profit, or administrative costs.
• The new plan landscape also demonstrates that the Medicare Part D prescription drug benefit will continue to provide beneficiaries with affordable access to drug coverage. The average premium for a basic Medicare Part D prescription drug plan in 2017 will remain relatively stable, at an estimated $34 per month. This is an increase of approximately $1.50 over the actual average basic Part D premium of $32.56 in 2016.
In addition, millions of seniors and people with disabilities with Medicare continue to enjoy prescription drug discounts as a result of the Affordable Care Act. Since the enactment of the Affordable Care Act through July 2016, more than 11 million seniors and people with disabilities have received savings and discounts in the coverage gap of over $23.5 billion on prescription drugs, an average of $2,127 per beneficiary thanks to the law.
The 2017 Rate Announcement and Final Call Letter advance broader efforts at the Department of Health and Human Services (HHS) and the Centers for Medicare & Medicaid Services (CMS) to move the Medicare Advantage and Part D prescription drug programs to provide high quality care for all Medicare beneficiaries, including low income and dually eligible beneficiaries.
• Higher quality of care – the 2017 Rate Announcement and Final Call Letter includes updates to the Star Rating system used to assess the performance of plans in providing high quality care. These updates will strengthen the accuracy of the evaluation system. The Call Letter also includes an interim analytical adjustment to account for the effect of low income subsidy/dual eligible and/or disability status on Star Ratings. The adjustment factor will vary by a contract’s proportion of low income subsidy/dually eligible and disability status beneficiaries. Through this interim adjustment, CMS seeks to more accurately capture true plan performance, while work continues by the HHS Assistant Secretary for Planning and Evaluation (ASPE) and measure stewards in this important area.

• Payment reform – the 2017 Rate Announcement finalized a new risk adjustment model that has separate coefficients for partial benefit dually eligible beneficiaries, full benefit dually eligible beneficiaries, and non-dually eligible beneficiaries. These changes will improve the precision of the payments made to plans, including increases in payments for plans serving full benefit dually eligible beneficiaries, and will support health equity and payment accuracy.

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