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Benchmark of the Week

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.

Now that the scores are in, you can assess the winners and losers of the final 2019 Medicare physician fee schedule, which increased the payment rates of some oft-used codes and slashed rates on others.


Denial rates for codes related to magnetic resonance imaging (MRI) under Medicare are not terrible, but watch out for a few high-rejection codes and make sure you’re keeping up on CMS and contractor news and changes on the ones you use.

When it comes to E/M payments, you’ll enter a business-as-usual cycle on Jan. 1 after CMS opted to delay its proposed sweeping changes for two years. But with a vast array of revisions on the books for 2021, it’s not too early to glimpse the financial outcomes of the single-pay rates and other changes looming ahead.
The growing wave of Medicare Advantage (MA) plans may increase the administrative time your practice spends chasing down prior authorizations, as the bulk of MA patients – about 80% – are in a plan that requires one for at least some services, according to new analysis from Kaiser Family Foundation (KFF).


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