These charts look at denial rates for both outpatient and inpatient E/M services in 2009 and 2010, for 10 specialties that have very high annual Medicare E/M utilization. Denial rates are higher for the high-level codes compared to the mid-level codes. Orthopedic surgery and urology have the highest denial rates regardless of code level, while hematology/oncology, pulmonary disease and dermatology are among the lowest.

Q. We have a Medicare patient diagnosed with 279.00 (hypogammaglobulinemia, unspecified) who is receiving 4 CC of gamma globulin every 30 days.  At this point we haven’t received any guidance from Medicare. Are we billing J1460 (gamma globulin 1 CC inj) correctly? Are there any modifiers used for this J-code that should be used? Will these claims get paid or denied?

This tool is a handy quick-reference chart that shows all five new Q-codes for flu vaccines, introduced in 2011. The chart, which in Microsoft Excel 97-2003 format, can be printed and posted in your office to help your billers, coders and clinicians distinguish between the Q-codes, listing their name, manufacturer, chareg and administration code, and dosage guidelines.

The number of new patient E/M visits and initial hospital care codes skyrocketed from 2009 to 2010, driven by CMS’s decision to eliminate consult codes effective Jan. 1, 2010. All consult codes (99241-99255) were non-billable in 2010 and providers billed 99201-99205 and 99221-99223 instead. This shift in billing had no effect on denial rates, which fell for all the codes that replaced consults, a Part B News analysis shows.

Negotiating and renegotiating payer contracts can be a complex and extensive task, says Mark Misiunas, a contracting specialist who runs Managed Healthcare Solutions, LLC in Atlanta. The first step is to decide whether your practice has the resources to prepare for and engage in contracting talks with payers, which can last anywhere from 30 days to six months, he says.

A wide variety of procedures top the list of high-denial codes that also saw a big jump in utilization from 2009 to 2010, the latest year for which CMS claims data is available. NOTE: Lab codes and supply codes were excluded from analysis, as were codes with low utilization, low denial rates and/or low utilization growth over the one-year period. NOTE: A slew of E/M codes, such as 99201-99205 and 99304-99306, saw the biggest growth in billing and had fairly high denial rates, but their utilization increases were a direct result of 2010 being the first year CMS stopped using consult codes. These other E/M codes were used as a replacement, boosting their utilization artificially (see related story).