Home | News & Analysis | PBN Benchmarks
Benchmark of the Week

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.

When it comes to documenting a helping hand during common surgical procedures, practices tend to turn to modifier AS (Physician assistant, nurse practitioner, or clinical nurse specialist services for assistant at surgery) rather than a range of CPT assistant-surgical modifiers — and find success in doing so.

Sometimes you can tell when CMS has its eye on a code from a sudden change in its denial rate — but only if you’re looking carefully, because it may just be happening under certain circumstances.

Practices and labs report millions of Medicare-covered screening services annually, yet some of the frequent fliers see denial rates approaching 50%, according to a Part B News analysis of Medicare claims data.

The specialties that are using transitional care management (TCM) codes 99495 and 99496 the most haven’t changed much since the codes were first paid by Medicare in 2013; what has changed is the rate of utilization — and, even more spectacularly, the rate of denial.\

In 2019, you’ll find 205 services and procedures that require personal physician supervision, the most rigorous level of oversight for mid-level providers, according to a Part B News analysis of the 2019 final Medicare physician fee schedule.

Part B News predicts in our lead story that chronic care management (CCM) utilization will reach 5 million claims in 2019, and data from the first three years in which Medicare paid for the service (2015-2017) suggests we’re on track — and that primary care providers are driving the increase.

Practices that report definitive drug tests continue to struggle with high denial rates, the latest Medicare Part B billing data for the tests shows. Because CMS has worked to curb improper reporting of the services, continued high denials may trigger audits and other intrusive measures. If investigators get involved, they could use strong-arm methods to wring large settlements out of practices.

Among a raft of codes that are on track to lose eligible service amounts in the new year, you’ll find a series of lesion-removal services and other integumentary procedural codes, according to the Correct Coding Initiative (CCI) version 25.0 edits taking effect Jan. 1

In past five years, providers have vastly improved their denial rates on codes with modifier 50 (Bilateral procedure), Medicare data show.


User Name:
Welcome to the new Part B News Online. If you are a returning user having trouble logging in, please click here.
Back to top