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Benchmark of the Week
X modifiers, introduced in 2015 as alternatives to 59 (Distinct procedural service), have been used successfully in many cases despite CMS’ lack of guidance or support for them (PBN 3/11/19). But be aware that not every code combo with an X modifier brings success.
Practices are finding some big wins when turning to the series of X modifiers that debuted with much fanfare – and ongoing questions marks – and that they’re allowed to use in place of the longstanding modifier 59 (Distinct procedural service).
Office E/M codes — 99201-99205 for new patients, 99211-99215 for established patients — are usually filed with the office place-of-service code (POS) 11, but they’re also filed from other sites and, to a surprising extent, accepted by Medicare contractors when they are.
Primary care practices and appropriate specialties may welcome additional coverage options and less cost-sharing among their patients who are tethered to the Medicare Advantage Value-Based Insurance Design (MA-VBID) model.

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.


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