Advantage Medical Billing Solutions

CMS Final Rule Changes E/M Reporting Guidelines for 2021

Linda J Sacco — Tue, 05 Jan 2021 19:52:21 +0000

Prolonged Services Changes

Code 99417 is the new prolonged services code for office visits (99205, 99215). However, CMS will require using the following code INSTEAD of 99417:

G2212 “Prolonged office or other outpatient evaluation and management service(s) beyond the maximum required time of the primary procedure which has been selected using total time on the date of the primary service; each additional 15 minutes by the physician or qualified healthcare professional, with or without direct patient contact (List separately in addition to CPT codes 99205, 99215 for office or other outpatient evaluation and management services)”

Even though this is for Medicare, there are some payers which state that they follow the Medicare guidelines. Therefore, you will need to check with individual payers and find out if they will be requiring 99417 or G2212 when billing prolonged E/M office services.

Visit Complexity Add-on

CMS has also created a visit complexity add-on code which may be reported, when applicable, with office visits. The new code is (emphasis added):

G2211 “Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition. (Add-on code, list separately in addition to office/outpatient evaluation and management visit, new or established)”

As you can see, this is aimed at providers managing more complex patient conditions, either a single serious condition or a complex condition. While CMS is not limiting this to certain specialties, they do anticipate that it will be most common in primary care. The following example was found in the final rule:

A 68 year-old woman with progressive congestive heart failure (CHF), diabetes, and gout, on multiple medications, who presents to her physician for an established patient visit. The clinician discusses the patient’s current health issues, which includes confirmation that her CHF symptoms have remained stable over the past 3 months. She also denies symptoms to suggest hyper- or hypoglycemia, but does note ongoing pain in her right wrist and knee. The clinician adjusts the dosage of some of the patient’s medications, instructs the patient to take acetaminophen for her joint pain, and orders laboratory tests to assess glycemic control, metabolic status, and kidney function. The practitioner also discusses age appropriate prevention with the patient and orders a pneumonia vaccination and screening colonoscopy.

It is clear that in the above example, the provider is providing longer-term care managing multiple organ systems.

NOTE: Do NOT report G2211 when reporting an office visit (99202–99215) with modifier 25.

Keep in mind that since this is related to E/M services, verify with individual payers if they will be following Medicare guidelines and if they will allow this code. Also, when reporting this code, be sure that the documentation clearly identifies how that the visit meets the code criteria.

References:

Medicare Physician Fee Schedule Final Rule

Happy New Year!

Linda J Sacco — Thu, 31 Dec 2020 18:44:23 +0000

We want to thank all of our clients and business associates for your continued support, generosity, and trust in our company. Thank you for allowing us to serve you this most challenging year and we look forward to serving you in the years to come.

Despite the ups and downs of 2020, we all have pulled together, and gotten through it. We move into 2021 with great aspirations and hopes for all of us. We look forward to our continued relationships and wish you and your families a Very Happy New Year with good health, & much success and happiness.

Happy New Year, Your partners and friends at Advantage Medical Billing Solutions!

Linda J Sacco, Founder & CEO

Medicare FFS 2% Payment Adjustment Suspended through March 31, 2021

Linda J Sacco — Wed, 30 Dec 2020 15:01:37 +0000

CARES (The Coronavirus Aid, Relief, and Economic Security) (CARES) Act suspended the payment adjustment percentage of 2% applied to all Medicare Fee-For-Service (FFS) claims from May 1 through December 31. The Consolidated Appropriations Act, 2021, signed into law on December 27, extends the suspension period to March 31, 2021.

Highlights of the 2021 CPT/Documentation Changes Effective January 1, 2021

Linda J Sacco — Sat, 26 Dec 2020 22:02:15 +0000

This year we have some rather important changes to be aware of. For some of you this will affect reimbursements and for all of you it will affect documentation. See below for the major changes:

Elimination of the History (H) and Physical Exam (PE) as elements (providers should perform a “medically appropriate history and/or examination” there will be NO required level of history or exam for 99202-99215.

Clinicians can now choose whether MDM or Time documentation can determine the appropriate E/M Code

MDM Modification 3 MDM subcomponents remain the same but there are extensive edits to elements for code selection.

Deletion of CPT Code 99201

Shorter Prolonged Service Codes, the definition of time is minimum time, not typical time and represents total physician/QHP time on the date of service (see below for what is included in time)

The care team may collect information and the patient or caregiver may supply information directly (by portal or questionnaire) that is reviewed by the reporting physician or other QHP

Time Documentation:

Physician or other QHP includes, preparing to see the patient including review of tests, obtaining/reviewing separately obtained history, performing medically appropriate exam/eval, counseling/education to patient/family/caregiver, ordering meds, tests, or procedures, referring and communicating with other health care professionals, documenting clinical info in EMR or other Health record, independent interpretation of results and communication of results to patient/family/caregiver, and care coordination.

Some new/revised key codes to add to your EMR and be aware of how to use them:

99415 Prolonged Clinical Staff Service direct patient contact with physician supervision. First Hour, note it doesn’t have to be continuous

99416 Prolonged Clinical Staff Service direct patient contact with physician supervision. Each Addl 30 minutes, it doesn’t have to be continuous

99417 Prolonged OV E/M service total time with or without direct patient contact each 15 minutes to be used ONLY with 99215 or 99205

99358 Prolonged Services Code w/o Direct Contact first hour regardless of POS

99359 Prolonged Services code w/o Direct contact first hour regardless of POS addl 30 mins

99354-99357 Prolonged Service Codes with Direct contact for physician or other QHP for Inpatient or Observation setting beyond the usual time.

We understand this may appear confusing; however, it’s extremely important that you understand how to use these codes in your practice; your revenue depends on it.

The most important thing to understand is documenting all of the pertinent medical information but now it’s also important to document start and stop times, time used consulting, time spent on the phone with family, caregivers and patients, time spend reviewing records etc.

You know the old saying “time is money”, well in this case it really is, so we are asking that you be mindful in your code selections. You will be using a combination of codes you may not have used before and you will need to document why.

Sit down with your staff and office manager and determine how this can be done if you haven’t done so already. For those of you who are clients feel free to reach out to us if you have any questions. As always we will be looking at your notes to insure that times are documented and code selection is correct based on the notes.

Have a Safe and Healthy 2021! Wishing you the best, Linda

Advanced Care Planning Billing and Reimbursement

Linda J Sacco — Fri, 10 Feb 2017 17:31:47 +0000

Many providers are not familiar with these codes and are missing out on the
reimbursement for these services. Let me explain services provided in order
to bill for these codes. The provider discusses and shares planning for the
future health care needs of the patient including Advance Directives. Examples
of written Advance Directives would include but not limited to are Health Care
Proxy, Durable Power of Attorney for Health Care, Living Will, or Medical Orders
for Life-Sustaining Treatment (MOLST). This discussion is typically 30 minutes
with the patient, his family, or someone representing the patient. Advanced care
planning focuses on the patient and involves both the patient and the provider
responsible for their care. It empowers the patient to make an informative decision
about their future care including their advanced care decisions. This gives
the patient the opportunity to express their preference for care depending on their
current and future health status and treatment options available. The provider may
enter the actual plan on forms specifically designed for that purpose in the
patients record.

There are two CPT codes for Advanced Care Planning, 99497 which are used for up
to a 30 minute discussion, and 99498 which is an add on code for each additional
30 minutes of the discussion. These codes can be billed at the same time as other
medical services taking place at the same visit before or after the time spent
on advanced care planning. Don’t forget to add a 25 modifier to the office visit
code. The 2017 Medicare allowed reimbursement amounts are 99497 $88.15
and 99498 $76.60.

I am certain many of you have provided these services to your patients and just
bundled it into the office visit code and losing out on and additional
$88-$164.00 per encounter. Add these codes to your superbill and your EMR
templates so they are not forgotten!

As always, Take Advantage for all of your outsourced medical billing needs!

The Impact of MACRA on Your Future Revenue

Linda J Sacco — Fri, 14 Oct 2016 21:35:26 +0000

What is MACRA? Presently providers are reimbursed on a fee for service basis. Fees that are determined by the SGR formula or Sustainable Growth Rate. MACRA (Medicare Access and CHIP Reauthorization Act) CHIP (Children’s Health Insurance Program) bottom line is the government wanting to reimburse providers based on their quality of care, not quantity. Physicians will no longer be reimbursed based on volume of patients but on the value of care.

MACRA’s implementation will begin in 2019 but will be based on the reporting year 2017. So, even though implementation is a few years down the road the data used to determine a providers fee schedule will be based on what is reported in 2017 which is only a few months away. MACRA will allow each provider to have an individual fee schedule based on performance. Under MACRA providers will have two options:

Option 1: MIPS or Merit Based Incentive Payment System. MIPS combines parts of PQRS, VM, and HER incentive program into one program. Most physicians will be reimbursed based on MIPS.

Option 2: APM or Alternative Payment Model. APM provides ways to pay health care providers for the care they give to Medicare beneficiaries by sharing the risk. Accountable Care Organizations (ACO’s), and bundled payment models are examples of APMs. From 2019-2024 health care providers that qualify for APMs will receive a lump-sum incentive payment.

There are four components of MIPS:

1. Quality – PQRS (50%)
2. Advancing Care Information (ACI previously known as HER/meaningful use) (25%)
3. Clinical Practice Improvement Activities (CPIA) (15%)
4. Resource Use (10%)

MIPS defines the financial impact on providers by creating a composite score for each provider. The composite score will be between 1 and 100 and based on the 4 components above. Composite scores will be posted on a CMS public website known as Physician Compare.

Providers not reporting PQRS measures now receive a 2% penalty. Once MACRA is implemented PQRS could have a big impact on a providers reimbursement as the PQRS portion of the score is 50%.

Currently meaningful use is an all or nothing program. Under MACRA, MU or ACI it will no longer be all or nothing. Under MACRA ACI will account for up to 25% of a providers composite score, the provider will receive credit for the amount of MU they demonstrate. The higher the providers composite score the more they will be reimbursed for services provided to Medicare beneficiaries.

It is important for providers to prepare NOW so that their reported information in 2017 will not hurt their income in 2019. Many providers are still not reporting through the PQRS system or demonstrating MU. The current penalty does not impact them enough to make a difference. With MACRA PQRS and MU will count for up to 75% of the composite score and won’t be as easily ignored.

It is imperative for providers to exercise financial prudence and start preparing now so that you’re not surprised in 2019 when revenues are harshly impacted.

And…as always Take Advantage for all your medical billing needs.

Whistleblower Doctor Warns About Hospitals Hiring Physicians

Linda J Sacco — Thu, 22 Oct 2015 21:00:44 +0000

Orthopedist Michael Reilly believes the surge of doctors going to work for hospitals is not a healthy trend. He had a firsthand view of what can happen

CMS Announces ICD-10 1 Year Grace Period

Linda J Sacco — Wed, 08 Jul 2015 13:03:17 +0000

There is no delay coming, but for one year after Oct. 1, CMS will pay for all claims that don’t have the correct ICD-10 codes as long as the codes used are in the ballpark. This is the biggest of several concessions CMS is making in light of the Oct. 1 deadline and the grave concerns providers have expressed with compliance. These measures will “allow for flexibility in the claims auditing and quality reporting process as the medical community gains experience using the new ICD-10 code set,” CMS said yesterday in a joint press release with the AMA.
It’s not a delay, but it is perhaps the most CMS could do short of continuing to accept ICD-9 claims after Oct. 1. Here’s a breakdown on the specific terms CMS announced.
• No claim denials. For the first year of ICD-10, from Oct. 1, 2015 to Oct. 1, 2016, Medicare claims will not be denied if the only problem was the use of inaccurate diagnosis codes. Any claim with ICD-10 codes in the appropriate family will be accepted and paid. Claims with ICD-9 codes will be not be accepted on or after Oct. 1, 2015.
• No ICD-10 audits. Medicare claims will not be audited based on the accuracy of ICD-10 diagnosis codes as long as they are from the appropriate family of codes. The idea is to give providers time to become familiar with the ICD-10 codes they’ll use, CMS said. Both Medicare carriers and Recovery Audit Contractors (RACs) will abide by this rule.
• No quality reporting penalties. Like the change to claim denials, CMS won’t penalize physicians under the Physician Quality Reporting System (PQRS), the value-based payment modifier, or the meaningful use program based on the specificity of diagnosis codes as long as codes from the correct ICD-10 family of codes are used
• Payment disruptions. If Medicare carriers have trouble processing claims because of the ICD-10 transition, CMS will allow advance payments to physicians.
• More communication. To stay on top of ICD-10 transition issues, CMS will create a special communications center to track problems during and after the run-up to October. A specific “ICD-10 ombudsman” will be named to sort through physician provider concerns and problems.
With only three months remaining before the ICD-10 deadline, these changes by CMS are the result of coordinated, even frenzied lobbying by physician groups, which, once assured that ICD-10 would not be delayed, pushed for some way to relax its potential financial impact.

“These provisions are a culmination of vigorous efforts to convince the agency of the need for a transition period to avoid financial disruptions during this time of tremendous change”, said AMA president Steven Stack, MD, in a statement. “These provisions are a testament to the power of organized medicine and what we can achieve when we band together for the food of our patients and our profession.”

Senate Passes H.R. 2 Legislation to Repeal and Replace the Medicare SGR

Linda J Sacco — Wed, 15 Apr 2015 19:49:47 +0000

Last evening, by a vote of 92 – 8 the Senate passed H.R. 2, legislation that would permanently repeal and replace the Medicare Sustainable Growth Rate formula (SGR). The six amendments offered during floor consideration were all defeated. The the Senate has passed the bill in the identical form as the House passed version. This means that the bill can immediately go to the President for his signature. The President has previously agreed to sign this bill into law.
Once signed into law by the President, this bill immediately repeals the SGR, retroactive to April 1st therefore averting a 21% reduction in Medicare fee-for-service (FFS) payments to providers. It replaces the SGR with a new payment system that includes automatic payment updates for physician fee schedule payments for five years, transitions Medicare FFS payments towards a value-based payment system and incentivizes the development and participation in new, alternative payment models, among other noteworthy provisions.

In an effort to minimize financial effects on providers, CMS previously instituted a 10-business day processing hold for all impacted claims with dates of service April 1, 2015, and later. While the Medicare Administrative Contractors (MACs) have been instructed to implement the rates in the legislation, a small volume of claims will be processed at the reduced rate based on the negative update amount. The MACs will automatically reprocess claims paid at the reduced rate with the new payment rate. No action is necessary from providers who have already submitted claims for the impacted dates of service.

The bill passed without reference to an ICD-10 delay, giving further momentum towards the Oct. 1, 2015 implementation deadline and creating increased urgency for those still preparing for the new medical code set.

Last year, House leadership slipped a last minute rider into SGR legislation, delaying ICD-10 for another 12 months. The postponement was the third in six years, blindsiding the healthcare community and discouraging ICD-10 proponents who were left wondering if the code set would ever see the light of day. With the passing of this bill and omission of any further ICD-10 delay legislation, those concerns now appear to be behind us.
Healthcare professionals who have been watching from the sidelines should begin preparing immediately, if they haven’t already. ICD-10 is the mandated replacement of the ICD-9 code sets used by medical coders and billers to report healthcare diagnoses and procedures. Its implementation will radically change the way documentation and coding are done and will require a significant effort to implement.

Are your ready for these changes? If not, we can help!
Call 1.877.666.5279

Billing for Prevnar 13? Concerned about Reimbursement?

Linda J Sacco — Wed, 08 Apr 2015 21:00:31 +0000

Prevnar 13 is a vaccine indicated for active immunization for the prevention of disease caused by streptococcus pneumonia serotypes. The average cost to the provider for this vaccine is $152.01 from Pfizer and comes in a 10 pack 1dose vial for a total cost of $1520.10. Due to the high cost we have been watching the reimbursements of this vaccine very closely. We don’t want any of our providers to be in the red with this one. As we move forward we will be providing analytical stats by insurance carrier on the actual reimbursements of the vaccine and the administration to insure that providers aren’t losing money by administering this vaccine.

If you are billing for this use CPT code 90670 for both Commercial plans and Medicare plans. Use G0009 for Medicare plan administration and 90471 for Commerical plan administration. We are using V03.82 which is pneumococcal vaccination when administered alone. Use V06.6 if patient is in your office to receive both the pneumococcal and influenza vaccinations during the same visit.

We are happy to report that reimbursements are reasonable and fair, so far we have received from $153.96 (Medicare) to $166.50 (Commercial), for the vaccine and $28.44 (Medicare) to $37.80 (Commercial), for the administration. This is just a very small sampling thus far, as the sampling gets larger the numbers will even out at a higher average. To date we have had no denials for any reason. Also note that the Medicare Part B deductible and coinsurance does not apply if patient is seeing a provider that accepts Medicare assignment.

As always, Take Advantage for all of your billing needs!