Home | News & Analysis | PBN Benchmarks
Benchmark of the Week

Some states took home outsize portions of the total revenue tied to two advance care planning codes — 99497 and 99498 — over the first six months of 2016.

Your chance of a denied claim goes up when you bill codes with modifier 59 (Distinct procedural service). In 2015, the most recent year available for Medicare claims data, claims with modifier 59 had a 19% denial rate versus a 16% denial rate without it. But that average fluctuates depending on specialty — and each of those specialties has its own highly denied codes when billed with 59.

Firm up your ICD-10 coding when your patient encounters are related to essential hypertension, immunization encounters, general adult and pediatric visits and other diagnoses tied to mass denials.

The ICD-10 codes reported most frequently to a major clearinghouse are pretty much what you’d expect — but their denial rates are much worse when they’re claimed as secondary diagnoses than when they’re claimed as the primary.
Practices may be in for a steep challenge with the new non-face-to-face prolonged service codes (99358, 99359) this year if the billing sheets on previously available prolonged services are any indication.
The list of Part B services with the most improper payments estimated by CMS for 2016 includes some of your most-billed services, according to data from the Comprehensive Error Rate Testing (CERT) program and other sources and published annually in the Medicare Fee-for-Service Improper Payments Report. Note that failure to establish medical necessity isn’t usually a factor; the mistake is more likely due to a coding error or a shortfall in documentation.
Some specialty groups may want to take a closer look at their coding and billing processes for office visit codes 99201-99215 after a new report from CMS details more than a billion-dollar blunder.
At first glance, it looks like not much has changed in denials for the 10 codes most often used with modifier 25 (Significantly, separately identifiable E/M service) over the past three years. As you can see in the chart, it’s mostly a matter of a point here, a point there.

The competition for a limited amount of incentive dollars tied to the merit-based incentive payment system (MIPS) may be fierce in 2017, as nearly two in five respondents to a recent medical practice survey said they would report multiple measures during the 2017 transition year.

Most codes that are frequently used with modifier 59 (Distinct separate service) have reasonable denial rates, but watch out for a few that seem to give providers trouble.


User Name:
Welcome to the new Part B News Online. If you are a returning user having trouble logging in, please click here.
Back to top