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Benchmark of the Week

You may not find the X-factor you need for getting your claims through with CMS’ quartet of X modifiers if new reporting numbers from Medicare tell us anything. However, in some cases you’ll find extra motivation – read: lower denial rates – to get more X modifiers on your radar.

If you haven’t been using X modifiers because you’re afraid it will increase denials, you may be surprised by their actual denial rates.

When it comes to billing transitional care management (TCM) codes 99495 and 99496, it appears practice truly does make perfect — or something close. Following some early hiccups, practices netted more than $103 million in reimbursement for TCM claims in 2015, the latest year of available Medicare claims data.

The historical benchmarks that will be used to determine quality measure scores sometimes can be deceiving. These tables, which use only the claims-based reporting benchmarks for process measures, give some idea of how you can find a “sweet spot” for your own reporting.

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.


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