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One genomic testing code skyrockets, another fluctuates, but denials remain lofty

02/10/2020

As practices find expanded coverage of Next Generation Sequencing tests, two CPT codes used most frequently — 81432 (Genomic sequencing procedures and other molecular multianalyte assays) and 81445 (Targeted genomic sequence panel, neoplasm, 5-50 genes) — are on divergent paths.

Protect your patients from Medicare scams with proactive education, tips

02/03/2020

by: Jim Dresbach

Medical practices that want to protect their patients should pay close attention to fraudsters looking to make major, illegal dollars off Medicare in 2020. Officials warn that scams tend to escalate when health care is in the news, and since 2020 is an election year, you can expect an increase in scammers seeking to raid Medicare accounts.

Direct Contracting, launching soon, pushes practices to put more skin in the game

02/03/2020

by: Roy Edroso

The Direct Contracting (DC) demonstration model that CMS is rolling out brings some free-market features to Medicare, letting practices negotiate with providers on how much of the capitated payments they’ll receive. Experts think this represents a trend in CMS’ approach to value-based care.

CMS warns on sleep studies: Watch coding, certifications and diagnoses

02/03/2020

by: Roy Edroso

Heads up: CMS, tipped off by OIG, is warning providers who do sleep studies to make sure they have appropriate documentation and don’t botch the billing of technicians.

Sleep study codes hold steady – but CPAP startup code is a denial trap

02/03/2020

by: Roy Edroso

While sleep studies and continuous positive airway pressure (CPAP) devices are getting more popular, Medicare billing for them so far has held pretty steady. But as the tough denial rates for a major CPAP code show, you still have to be careful about billing them.

Heed payer-specific guidelines to avoid denials when using modifier 25

01/27/2020

by: Sarah Gould

Steer clear of common obstacles that can derail your use of modifier 25 (Significant, separately identifiable E/M service) and leave you with yawning gaps in revenue. When applying this modifier, coders must consider CPT reporting rules and adhere to potentially restrictive billing rules followed by their payers.

2020 strategic planning strategy, part 2: Avoid threats to your business, pursue strengths

01/27/2020

by: Roy Edroso

In Part One of the 2020 strategic planning feature, published Jan. 13, we discussed how to identify leading indicators to optimize your business plan and operational success. In Part Two, below, you’ll find out how to anticipate threats and read success tips from a start-up solo practitioner.

Heed payer-specific guidelines to avoid denials when using modifier 25

01/27/2020

by: Sarah Gould

Steer clear of common obstacles that can derail your use of modifier 25 (Significant, separately identifiable E/M service) and leave you with yawning gaps in revenue.

Take stock of federal value-based model performance to weigh risks, opportunities

01/27/2020

by: Jim Dresbach

You should be monitoring the performance of alternative payment models (APM) that CMS and its Innovation Center have launched in recent years under non-traditional payment structures.

Hyberbaric oxygen therapy claims, under CMS’ gaze, seesaw between 2015 and 2018

01/27/2020

by: Jim Dresbach

Medicare claims data for non-emergent hyperbaric oxygen (HBO) therapy and the introduction of a prior authorization model to support the procedure disclosed numbers that show the CMS program is working as intended — to curtail overuse.

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