Tag: medical coding

Overview of MACRA, QPP, & MIPS

MACRA is landmark, bi-partisan legislation passed by Congress.  It is designed to dramatically shift the payment of healthcare from the current Volume Based Reimbursement model to a model based on quality and cost effectiveness. MACRA repealed the flawed Sustainable Growth Rate, phased out Meaningful Use, PQRS and the Value Based Modifier programs. It created two…


How to Avoid Denials for Excisions and Repairs

In the recent AAPC article “Know When to Report Excision or Repair (or Both),” the coding rules for performing excisions and repairs for both malignant and benign lesions are described. The following decision tree provides guidance on when it is appropriate to report repairs separately (per AAPC): Is it a simple repair (e.g., involving “primarily…


Importance of E/M Outliers for Current Clients

In today’s coding environment, internal auditing is an important business process for avoiding costly repayments and other punitive measures for bad billing. Evaluation and Management (E/M) services are always highly monitored by auditors since those services represent such a large percentage of Medicare Part B billing. What to know Your internal auditors ought to be familiar with their…


Importance of E/M Outliers

In today’s coding environment, internal auditing is an important business process for avoiding costly repayments and other punitive measures for bad billing. Evaluation and Management (E/M) services are always highly monitored by auditors since those services represent such a large percentage of Medicare Part B billing. What to know Your internal auditors ought to be familiar…


CLDPP to Combat Increasing Payor Rules

AMA’s 2012 National Health Insurer Report Card provides interesting insight into what the revenue cycle might look like in the next few years (Learn more about the AMA 2012 Report Card, here). There are two interesting observations on the data that need to be considered with respect to what types of tools provider organizations will need in the future…


Even with EHRs, Practices Continue to Manually Code

In a recent report by the Office of Inspector General (OIG), OIG auditors observed that the majority of physicians who have adopted EHRs continue to code Evaluation and Management (E/M) services manually—even though most major EHR vendors offer technology that will code E/M services automatically.

For the past decade, the OIG has kept a close eye on E/M coding because the level of E/M visits reported are trending higher at present than in previous decades. EHR adoption is intended to increase the accuracy of medical coding (e.g., E/M codes); however, this report suggests that physicians still prefer to code E/M visits the “old fashioned” manual way rather than adopt a new technology to automate the process. 

The OIG report did not offer any insight as to why physicians are still coding E/M visits without the help of EHR tools. Some theories include: E/M modules cost more money on top of an already expensive EHR system, E/M templates are not user friendly to the physicians, or physicians may not trust any EHR system to code for visits that affect such a large percentage of the revenue. Regardless, physicians often code E/M visits incorrectly, resulting in either over or underpayments.

If EHRs are not proving useful in coding this area of medical services, then physicians must look to other sources to avoid coding errors during claims review.

 


Coding Multiple Surgical Procedures

When physicians perform multiple surgical procedures on a patient during the same session, certain rules must be applied in order to code the claim correctly. Claims must be reviewed to make sure the codes are reported in compliance with bundling rules, National Correct Coding Initiative (NCCI) edits, and relative value units (RVUs). Code Order Matters…


Coding Multiple Surgical Procedures for Current Clients

When physicians perform multiple surgical procedures on a patient during the same session, certain rules must be applied in order to code the claim correctly. Claims must be reviewed to make sure the codes are reported in compliance with bundling rules, National Correct Coding Initiative (NCCI) edits, and relative value units (RVUs).

Code Order Matters

Surgeons are paid at 100% of the fee schedule for the primary surgical procedure, and at 50% for all subsequent surgical procedures performed during the same surgical session. As such, the procedure with the highest RVU should always be listed first. The Medicare Physician Fee Scheduled Database (MPFSDB) lists the RVU value for each surgical CPT® or HCPCS code. The MPFSDB is updated annually, and the current version is located on The Centers for Medicare & Medicaid Services (CMS) website

If a surgical code with a lower RVU value is listed as the primary surgical procedure on the claim, insurance companies will pay the claim at the lower RVU rate—leading to a lower reimbursement rate.

Current Clients: White Plume’s AccelaSMART product offers Procedure Sequencing at the click of a button, relieving pressure on the billing staff to remember the RVU of all procedures.

Watch out for Unbundling

CMS developed the National Correct Coding Initiative (NCCI) to prevent invalid code combinations from being paid. NCCI edits are classified into two major categories:

  • Column 1/Column 2 Edits (Status 0) – Code pairs that are not normally reported together because one of the procedures is already considered a component of the other procedure
  • Mutually Exclusive Edits (Status 1) – Code pairs that are not reasonably performed together in the same operative session for anatomic reasons

Code pairs with a status indicator of 0 cannot use modifiers to override the NCCI edits. However, code pairs with status indicator of 1 can use certain modifiers to bypass an NCCI edit, when used appropriately. These modifiers include the following:

  • Anatomic modifiers: E1-E4, FA-F9, TA-T9, LT, RT
  • Coronary artery modifiers: LC, LD, RC
  • Global surgery modifiers: 58, 78, 79
  • Other modifiers: 59

Click here to access a list of NCCI edits.  

Current Clients: The AccelaSMART validation product contains the NCCI edits including “Status 0” verses “Status 1” information. If a code pairing violates bundling edits, our messages will tell you if the pair accepts a modifier for correction or not. The message even suggests the appropriate modifier. The user does not have to research the pair! 

Modifier 59

Modifier 59 is often used to report subsequent procedures that are separate and distinct from the primary procedure. The criterion for “separate and distinct” means that the procedure was performed:

  • During a different operative session
  • On a different organ
  • On a different incision or excision
  • For a different injury or lesion

Current Clients: The AccelaSMART validation engine alerts users when a Modifier 50 is acceptable and suggest review of documentation to ensure it is a valid submission for the encounter.


KX Modifier Overpayment

On April 20, the Office of Inspector General (OIG) published a report explaining the use of the KX modifier. Seen most often with physical and occupational therapy billing, providers add a KX modifier to CPT® or HCPCS codes in order to show there is documentation on file justifying the need for that procedure, service, or supply, and the documentation meets Medicare coverage criteria.

Of the claim samples reviewed, the OIG found less than 50 percent of the claims containing a KX modifier had the appropriate supporting documentation. As such, the OIG estimates contractors paid approximately $316.4 million in unallowable Medicare payments to suppliers.

According to the report,

“These errors occurred because the contractors did not supplement their electronic edits with sufficient prepayment and post payment review to ensure that suppliers maintained required documentation. The edits could determine only whether the required KX modifier was on the claims and did not prevent payments for unallowable claims.”

Providers may soon begin receiving letters from insurance companies that pay for durable medical equipment (DME) in an attempt to recoup overpayments.

Since the problem with the KX modifier is from lack of documentation, adding an edit in your practice’s code review engine (e.g., AccelaSMART) can remind the coder to verify there is proper documentation before submitting the claim. When asked to pay back the contractor, first attempt to refile the claim with proof of documentation for the service. If no documentation is available, then repayment must be made.


Medical Code Scrubbing and EMR Templates

Many medical coding solutions and claim scrubbers promise a way to recover the savings from automating the charge entry process when using an EMR template. When looking for a solution, realize the ideal solution should not be an afterthought or one feature on a list of a hundred features. A coding solution should be carefully examined to determine:

  • What types of rules does it include
  • When are these rules applied
  • Who reviews these errors and makes the corrections
  • How are the errors presented and corrections made

Medical coding is extremely complicated and is critical to the revenue of the practice. Make sure that you select a medical coding and claim scrubbing solution that is up to the task.