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Benchmark of the Week
Though CMS estimates that one in five Americans aged 65 years and over has either type 1 or type 2 diabetes, Medicare’s codes for services that help diabetic patients cope with their disease have not performed very strongly in recent years, and are beset with high denial rates.
Providers pulled in nearly $1.5 billion in payments for subsequent nursing facility encounters in 2019, continuing a strong rate of growth largely fueled by an uptick in nurse practitioner visits.
While it’s not used as often as other care management services in Medicare Part B, transitional care management (TCM) has witnessed steady growth overall, and its denial rates remain low. But there are some provider types claiming from some facility types that don’t do so well with them.
Medical practices showed a tepid response to the launch of a series of interprofessional consultations in 2019, the first year that CMS approved the codes for reimbursement.
It may not be the high overall denial rates that best explain why the two interrupted-service modifiers, 52 (Reduced services) and 53 (Discontinued procedure), are so tricky; it could have something to do with the mix of codes that seldom, if ever, get denied with the modifiers, and those that get rejected most or all of the time.
Payment cuts to a series of immunization administration codes have significantly curtailed provider payments in recent years, as Medicare slashed rates for the G0008-G0010 series related to influenza, pneumococcal and hepatitis B vaccines.
Practices accelerated their use of advance care planning codes 99497 and 99498 in 2019, as more providers held – and billed for – important late-life planning sessions with patients.
While the total number of established E/M office visit claims (99211-99215) decreased in recent years, providers still netted a payment increase because of a continued use of Levels 4 and 5 codes.
While the volume of Welcome to Medicare visits has grown modestly and initial annual wellness visits (AWVs) have declined in recent years, the use of subsequent AWV claims has surged at a 26% growth rate.
Providers are taking a cautious jump into a suite of remote monitoring and virtual evaluation services that Medicare has approved for use in recent years, but the early returns reveal significant revenue possibilities.


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