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Benchmark of the Week

The historically high denial rates on initial preventive physical examination (IPPE) and annual wellness visit (AWV) codes have seen a slight dip — even when billed with modifier 25 (Significantly, separately identifiable E/M service), commonly used when the physical results in a procedure.


You’ll find sky-high improper payment rates for several groupings of lab codes spanning glucose testing, urinalysis, blood counts and others, according to CMS data from the 2016 Improper Payments Report.

Medicare allows hyperbaric oxygen therapy for conditions ranging from cyanide poisoning to necrotizing fasciitis to decompression illness. But a remarkable number of the Medicare claims for 99183 (Physician or other qualified health care professional attendance and supervision of hyperbaric oxygen therapy, per session) were supplied under primary care in 2015, according to the most recent Medicare claims data. And for providers of any kind, the denial rates weren’t so hot.

Payments for obesity-counseling code G0447 (Face-to-face behavioral counseling for obesity, 15 minutes) continue to climb as the service gains traction among medical practices.

You may wonder whether National Government Services (NGS) has a specific reason for making it more challenging to reach higher-level E/M requirements with new exam specifications, while other Medicare administrative contractors (MACs) have not. Data suggests it doesn’t have to do with any unusual patterns in E/M billing denial rates in the 10 states NGS covers versus the rest of the country.

You may not find the X-factor you need for getting your claims through with CMS’ quartet of X modifiers if new reporting numbers from Medicare tell us anything. However, in some cases you’ll find extra motivation – read: lower denial rates – to get more X modifiers on your radar.

If you haven’t been using X modifiers because you’re afraid it will increase denials, you may be surprised by their actual denial rates.

When it comes to billing transitional care management (TCM) codes 99495 and 99496, it appears practice truly does make perfect — or something close. Following some early hiccups, practices netted more than $103 million in reimbursement for TCM claims in 2015, the latest year of available Medicare claims data.

The historical benchmarks that will be used to determine quality measure scores sometimes can be deceiving. These tables, which use only the claims-based reporting benchmarks for process measures, give some idea of how you can find a “sweet spot” for your own reporting.

Some states took home outsize portions of the total revenue tied to two advance care planning codes — 99497 and 99498 — over the first six months of 2016.


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