Part B News | Part B News

Payments rebound, denials tick up for inpatient/obs combo codes

11/04/2024

Part B providers reporting inpatient and observation care codes appeared to face minor but notable headwinds as they adapted to the AMA’s revised reporting guidelines in 2023. Payments increased for some of the oft-reported codes in 2023, but denial rates also crept up for some of the most-billed services.

Use 4 documentation points to square away modifier 25 troubles

10/28/2024

by: Julia Kyles, CPC

Your practice can receive separate payment for an E/M visit on the same day as a minor procedure by using 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).

Will Fla. ruling mean the end of qui tam? Not right away

10/28/2024

by: Roy Edroso

A federal judge has declared the qui tam (whistleblower) provisions of the False Claims Act (FCA) unconstitutional. This ruling has the potential to end the incentives that drive most FCA prosecutions, including those in health care. Experts have mixed opinions as to how this ruling will play out in higher courts, but even before it’s retried it may affect how such cases are brought and defended.

Home BP readings for ‘white coat hypertension’? OK, but probably not RPM.

10/28/2024

by: Roy Edroso

Question: I have a patient who claims “white coat hypertension” — that is, he says his home blood pressure readings are significantly lower than the ones we get in the office. He has a home BP device, a Pressure X Pro, that connects to the internet. Can I take a reading via this device? And, in addition to adding it compliantly to encounter notes, can I claim 99091 (Collection and interpretation of physiologic data [eg, ECG, blood pressure, glucose monitoring])?

When coding eating disorders, start with initial visit, include all services

10/28/2024

by: Son Hoang

Question: What codes should a coder consider for a patient diagnosed with an eating disorder (e.g., anorexia nervosa, bulimia nervosa, and avoidant/restrictive food intake disorder)?

HHS issues RFI for Part D ‘$2 drugs’ on some widely-used prescriptions

10/28/2024

by: Roy Edroso

Adding to its other pioneering prescription drug programs under Medicare, the Biden administration announced Oct. 9 that it would issue a request for information (RFI) on a potential “Medicare $2 Drug List Model” that would make some much-used drugs for hypertension, high cholesterol and other common conditions available to Part D beneficiaries for a couple of bucks.

Modifier 25, highly used, tops $4B in associated payments

10/28/2024

by: Julia Kyles, CPC

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) continues to see high utilization. Providers reported it on more than 65 million claims in 2023.

Discover guideline revisions, 400+ code changes in 2025 CPT update

10/21/2024

by: Laura Evans, CPC, Julia Kyles, CPC, and Richard Scott

Get ready to dig into more than 400 code changes as part of the 2025 CPT code set. That includes 270 new codes, including dozens of surgical codes, as well as 112 deletions and 38 revisions.

MA plans lose stars, customers; will they also lose their enrollment lift?

10/21/2024

by: Roy Edroso

A big drop in the star ratings for Medicare Advantage plans is just the latest in a series of recent challenges to the public-private coverage program. MA enrollments are increasingly up and set to outstrip traditional Medicare, but challenges like this one are increasingly noisy. While this doesn’t mean the program will reverse course, some payers already are making big changes to cope.

Share details, 6 tips on the 16 new telemedicine E/M codes

10/21/2024

by: Julia Kyles, CPC

Take in the details of the 16 new telemedicine codes for real-time encounters in the CPT 2025 manual while you wait to see whether private payers adopt the services or CMS sways from proposed non-coverage of the codes.

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