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Unbundling is undoing: DOJ orders $3 million fee on bad 25, 59, XU claims

09/27/2021

A $3 million settlement of False Claims Act charges stemming from inappropriate use of the modifiers 25 (Significant, separately identifiable E/M service), 59 (Distinct procedural service) and XU (Unusual non-overlapping service) is a warning to keep an eye on habitual use of these modifiers that allow extra charges during patient encounters.

Regulatory roundup: Telehealth abuzz in PFS response; CMS kills MCIT, updates No Surprises

09/27/2021

by: Roy Edroso

Monitor the public comments and activity around a series of recent federal rules, and you may gain an early glimpse of regulatory updates coming your way. Recently, comments closed on the proposed 2022 Medicare physician fee schedule, revealing major concerns of medical organizations and other stakeholders; and, in separate updates, CMS issued a new rule related to the No Surprises Act and changed course on how to make “breakthrough technology” available to patients.

CMS plans to tinker with Stark compensation arrangements, again

09/27/2021

by: Marla Durben Hirsch

If your practice has indirect compensation arrangements (ICA) with hospitals, labs or other designated health service providers, you may need to revisit those agreements. CMS is proposing to update the Stark physician self-referral rule to make more ICAs subject to Stark’s requirements.

Streaming a family update via Zoom? Don’t bill as an office visit

09/27/2021

by: Julia Kyles, CPC

Question: My doctor had a telehealth visit with a 75-year-old patient who has well-controlled diabetes and mild cognitive decline. A week later, with the patient’s permission, the physician gave the patient’s adult daughter an update on her father’s health. The conversation took place through Zoom and lasted 23 minutes. The patient wasn’t present. Can we bill the conversation to Medicare as an E/M visit (99202-99215) under the special rules for telehealth services or, alternatively, the new E/ M guidelines?

OIG says CMS overpaid physicians $1.7 million for TCM services

09/27/2021

by: Sarah Gould

CMS overpaid physicians an estimated $1.7 million for transitional care management (TCM) services over a two-year period, according to a recent Office of Inspector General (OIG) report. Overpayments were due to CPT coding and billing errors.

Medicare FFS enrollment sputters as Medicare Advantage moves in

09/27/2021

by: Roy Edroso

The latest Medicare enrollment numbers show that while Medicare Advantage continues to gain a share of covered patients, traditional Medicare is fading fast.

Refusing care to the unvaccinated a potential legal and ethical pitfall

09/20/2021

by: Roy Edroso

Recent reports of providers refusing to treat patients who are not vaccinated against COVID-19 raise the question: Can providers do that? While there are technical grounds that would arguably allow it, legal experts advise against it.

Federal vaccine mandate could require shot or test for nearly all health care workers

09/20/2021

by: Roy Edroso

The impact of the Biden administration’s vaccine mandate will be more apparent when rulemaking and other sub-regulatory guidance emerges, but it appears that nearly all U.S. health care workers will be required to vaccinate against COVID-19 or take regular COVID tests as a condition of employment.

CCI version 27.3 edits reverse E/M bundles, lock in more code pairs

09/20/2021

by: Julia Kyles, CPC

Mind the latest quarterly National Correct Coding Initiative (CCI) update, which includes a reversal of procedure-to-procedure (PTP) edits that involve E/M codes along with new medically unlikely edits (MUE) for a series of COVID-19 vaccination codes. The edits, released in early September, will go into effect Oct. 1.

Is it an independent interpretation or review of test results? Here’s how to tell

09/20/2021

by: Laura Evans, CPC

As practices adjust to the 2021 E/M office visit guidelines, one area of debate has continued to circulate around when it is appropriate to count an “independent interpretation” versus a review of “the result(s) of each unique test,” as the guidelines define them.

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