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Create a plan to defend modifier 25 claims ahead of new Cigna policy

05/01/2023

Your practice should stand firm on compliance and reimbursement when it submits E/M claims with modifier 25 (Significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service).

New ACA rule makes keeping coverage easier for beneficiaries

05/01/2023

by: Roy Edroso

If you have patients with Affordable Care Act (ACA) marketplace plans, changes announced in the HHS/CMS Notice of Benefit and Payment Parameters for 2024, released April 17, are likely to make it easier for them to remain in the program. Also, heads up: Though HHS has delayed it, in 2025 plans can be penalized for missing certain access-to-care targets, which may affect how those plans add providers to their networks.

Make sure time is on your side for discharge day documentation

05/01/2023

by: Julia Kyles, CPC

Train your providers to capture the time for all discharge day management visits. If they stick to the strictest standard, you won’t have to wonder if your claims will meet a specific payer’s policy.

Latest Category III codes address shoulder, spine, cartilage injuries

05/01/2023

by: Laura Evans, CPC

Among the batch of CPT Category III codes that took effect Jan. 1, 2023, practices will find two codes for cutting-edge regenerative musculoskeletal procedures, one for use of animal implants and a code for facet joint replacement at a single vertebral level.

OIG issues audit guidelines for telehealth risk

05/01/2023

by: Roy Edroso

On April 24, OIG released a toolkit for “Analyzing Telehealth Claims to Assess Program Integrity Risks.” The toolkit is based on investigations during the first year of the pandemic which revealed, OIG says, “Medicare beneficiaries used 88 times more telehealth services” than they did previously.

Consider this rule of thumb when selecting MDM complexity for fracture care

05/01/2023

by: Laura Evans, CPC

Question: If a patient has a fractured femur and ankle would this be considered high complexity when coding based on medical decision-making? Just looking for more clarification on what the AMA’s E/M guidelines consider “poses a threat to life or bodily function.”

X marks the spot: XS, XU modifiers outclass 59 in denial rate battle

05/01/2023

by: Richard Scott

In a head-to-head showdown, the series of X modifiers that CMS permits for two or more procedures on the same date of service turned in favorable performances compared to modifier 59 (Distinct procedural service), even as total X-modifier claims came in low.

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