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Benchmark of the Week

Modifier 76 (Repeat procedure or service by same physician) is a pretty good bet in most cases, but there are a lot of codes for which it’s seldom or never accepted.

As practices find expanded coverage of Next Generation Sequencing tests, two CPT codes used most frequently — 81432 (Genomic sequencing procedures and other molecular multianalyte assays) and 81445 (Targeted genomic sequence panel, neoplasm, 5-50 genes) — are on divergent paths.

While sleep studies and continuous positive airway pressure (CPAP) devices are getting more popular, Medicare billing for them so far has held pretty steady. But as the tough denial rates for a major CPAP code show, you still have to be careful about billing them.

Medicare claims data for non-emergent hyperbaric oxygen (HBO) therapy and the introduction of a prior authorization model to support the procedure disclosed numbers that show the CMS program is working as intended — to curtail overuse. 
Even before the accommodations that CMS made for non-physician practitioners (NPPs) kicked in this year, the two biggest NPP specialties in Medicare were performing in overdrive. Other NPP groups, however, are falling off the pace.
The time-based codes for advance care planning (ACP), 99497 and 99498, that debuted in 2016 have witnessed strong utilization and payment increases over the past three years.

Many providers anticipate seizing the new chronic care management (CCM) add-on code that’s debuting Jan. 1, 2020, but far fewer plan to dive into the virtual realm of tech-backed E/M services in the new year.

Despite CMS’ dithering, X modifiers seem to have picked up some slack from modifier 59 (Distinct procedural service) since being introduced in 2015.

Nurse practitioners, orthopedic surgeons, general surgeons and family practice providers have all faced significant hurdles with their 99201 claims, with denial rates ranging from 10% to 22% in 2018, the latest year of available Medicare claims data. But no specialty matched chiropractic’s dismal return — a 100% denial rate on nearly 93,000 services, with a loss of $5 million.

The two skin biopsy codes that were replaced by six more specific codes this year experienced huge growth in the past 10 years, which may explain why the switch was made.


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