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Benchmark of the Week
Cardiologists, internal medicine providers and nephrologists are the most likely specialty groups to report a series of ambulatory blood-pressure monitoring codes that, ultimately, don’t get much attention.
Looking at Part B denial rates for modifiers 52 (Reduced services) or 53 (Discontinued procedure), it appears easier to get contractors to buy your reasons for stopping a procedure than your reasons for curtailing it, according to claims data from 2017, the most recent available.

Select few specialists, most notably ophthalmologists, report the bulk of procedural services with modifier 54 (Surgical care only), which denotes the work tied to the pre-operative and intraoperative pieces of the surgical puzzle.

Denial rates for the most popular screening and counseling codes for depression and alcohol and substance abuse are not great, and in one case forbidding. Make sure you get the little things right on your claims.

Various specialties tend to generate different amounts of work relative value units (RVUs) under CMS’ current pricing system, and those differences are tied to payment chasms, a March 15 report from the Medicare Payment Advisory Commission (MedPAC) states.

X modifiers, introduced in 2015 as alternatives to 59 (Distinct procedural service), have been used successfully in many cases despite CMS’ lack of guidance or support for them (PBN 3/11/19). But be aware that not every code combo with an X modifier brings success.
Practices are finding some big wins when turning to the series of X modifiers that debuted with much fanfare – and ongoing questions marks – and that they’re allowed to use in place of the longstanding modifier 59 (Distinct procedural service).
Office E/M codes — 99201-99205 for new patients, 99211-99215 for established patients — are usually filed with the office place-of-service code (POS) 11, but they’re also filed from other sites and, to a surprising extent, accepted by Medicare contractors when they are.
Primary care practices and appropriate specialties may welcome additional coverage options and less cost-sharing among their patients who are tethered to the Medicare Advantage Value-Based Insurance Design (MA-VBID) model.

You already know that the prior authorization required on many procedures, services and drugs by private and Medicare Advantage plans can be an enormous hassle for your providers and staff. But the most alarming finding in the AMA’s latest physician poll on prior authorizations is that more than a quarter of respondents reported serious patient medical issues attributable to resulting care delays.


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