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Benchmark of the Week

Many specialty groups beyond primary care took in significant chronic care management (CCM) payments in 2015, with the $31.3 million in reimbursement spread across dozens of specialties.


Of the six eye exam codes eye that will be bundled in new CCI code pairs, four had relatively stable denial rates between 2011 and 2015 — but two of them had remarkably high and much less stable denial rates.

Some specialty providers, including those in pathology, nephrology and orthopedic surgery, may have a difficult time seizing payments for apheresis services following a supervision change in one Medicare administrative contractor’s (MAC’s) jurisdiction.

With a few exceptions, Medicare providers seem to have a pretty good understanding of modifier 26 (Professional services) and see denial rates mostly lower than 10%, though some notable exceptions exist.

As a new flu vaccine debuts in 2017, the vaccine’s billing rules hold cross-specialty appeal because primary care providers are not the only ones to report flu claims.
The use of therapy modifiers — GO (Services delivered under an outpatient speech language pathology plan of care); GN (Services delivered under an outpatient occupational therapy plan of care); or GP (Services delivered under an outpatient physical therapy plan of care) — changes the billing results on always- and sometimes-therapy codes, especially if you’re a therapy provider using the wrong one.
Payments for E/M services appended with modifier 25 (Significant, separately identifiable E/M service) topped $2.5 billion in 2015, according to the latest available Medicare claims data.
CMS’ proposal to let 19 preventive services codes be billed with prolonged service add-on codes is good news to many providers. But it’s only good if they can get those codes accepted in the first place — and some of them have given providers trouble.
Clinical social workers, psychologists and podiatrists are among 11 specialty groups slated to receive additional payments for their services in 2018, according to projected allowed charges contained in the proposed 2018 Medicare physician fee schedule.

Denial rates on key vaccine codes from 2013 to 2015, which are the most recent years for Medicare data, have been remarkably consistent and suggest that billing problems with some codes are due to long-known issues. The data also suggest many practices just haven’t caught on yet.


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