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Benchmark of the Week
It’s a topsy-turvy fee outlook in 2021, as medical practices are projected to see wild fluctuations in Part B charges in the new year. With specialty-specific gains reaching as high as 16% – and losses also reaching double digits – your billing patterns are likely to tell how your Medicare charges will fare.
Considering its stringent requirements, you may expect claims with modifier 24 (Unrelated E/M service during a postoperative period) to see a lot of denials. But their rates are actually very low, especially compared to where they were four years earlier.
The critical care code set may be small in size, consisting of two CPT codes (99291, 99292), but it packs a wallop when it comes to provider revenue. In 2019, practices surpassed the $1 billion mark in payments tied to the two codes.
CMS released its Part B claims numbers for 2019 on Nov. 5, and the yearly numbers show nearly everything growing except two areas: denial rates and E/M utilization.
Check the time and other possible billing hazards for advance care planning (ACP) claims. The two ACP codes (99497, 99498) show an average denial rate of 19% since Medicare started covering the service, which may be a sign that practices are making easy-to-avoid mistakes for the two codes.
Provider payments for two psychiatric diagnostic evaluation codes (90791, 90792) maintained steady growth in recent years, returning more than $140 million in fees in 2018, the latest year of available Medicare claims data.
Providers seem to vastly favor using modifier 25 (Significant, separately identifiable E/M service) in mid-level established patient visits over any other. But it gets a workout with other codes as well – some of them inappropriately.
Providers have been slow to make an entrance into the Medicare Diabetes Prevention Program (MDPP), which offers a series of payments to fight the rising rates of type 2 diabetes.
It’s still a traditional-Medicare world, but if trends continue, it won’t be for long.
The number of office E/M codes that nurse practitioners (NP) are reporting under Medicare Part B has been on a significant upswing in recent years. Total claims for their most-billed office code, 99214, are up 114% from 2014 to 2018.


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