Scenario 1 History: A 45-year-old male patient with sero-negative rheumatoid arthritis affecting multiple sites, but with no organ or systems involvement, comes for a follow-up visit. The patient reports swelling of the left knee with throbbing left knee pain. He rates the severity of his pain at an 8 on a 10-point scale. The pain…
2019 Proposed Rule for MIPS Performance Year 3
The CMS has submitted its annual proposed rule, which continues the transition to a value-based model, for comment by stakeholders and the public for the 2019 MIPS performance year (Jan. 1–Dec. 31, 2019).
UHC Announces New Policy on National Drug Code Requirement
Effective Sept. 1, 2018, United Healthcare’s (UHC) new policy for National Drug Code (NDC) reimbursement will require providers to include additional drug-related codes submitted on the CMS-UB04 and the Electronic Data Interface (EDI) transaction 837i. All outpatient claims submitted to UHC commercial and UHC Medicare Advantage plans with a date of service on or after…
How to Document the Physical Exam
The adage frequently cited in healthcare settings, “If it isn’t documented, it wasn’t done,” still rings true for the key components required in a patient’s medical record. The note in the medical record must sufficiently describe all of the services furnished to patients on a specific date. The essential requirements to appropriately bill a claim…
Coding Corner Answer: Evaluation & Management Documentation Quiz
Take the challenge. B—The presenting problem(s) is what is evaluated during the history and examination by the provider. The chief complaint is in the patient’s own words or is a follow-up for his or her current condition. The history of present illness, along with the review of systems, usually guides the provider through the examination….
Coding Corner Question: Evaluation & Management Documentation Quiz
Evaluation & Management Documentation Quiz What element drives an evaluation and management (E/M) visit? The chief complaint in the patient’s own words of why he or she is in the practice for that date of service. The presenting problem(s) being discussed with the physician for that patient during the visit. The examination performed on the…
CMS Releases 2018 MIPS Eligibility Tool
You can now use the updated Centers for Medicare & Medicaid Services (CMS) MIPS Participation Lookup Tool to check on your 2018 eligibility for the Merit-Based Incentive Payment System (MIPS). Enter your National Provider Identifier (NPI) in the tool to find out whether you need to participate during the 2018 performance year. Changes to…
Understanding & Preparing for Payer Audits
Audit activity among Medicare and most third-party payers has increased in response to pressure to reduce healthcare costs. The return of billions of dollars to Medicare, Medicaid and third-party programs through these medical audit reviews has also increased. For example, the Government Accountability Office (GAO) 2014 Annual Report estimated that the Centers for Medicare &…
Different Payer Audits Require Different Preparation & Response
For a provider of healthcare services, payer audits are always a possibility. Both government and private payers consistently monitor providers to prevent fraud, overpayment, and improper billing or coding procedures. Audits can be nerve-racking and intimidating, even if a provider is billing correctly. Improper billing can lead to civil and criminal sanctions. To alleviate some…
Rheumatology Coding Corner Answer: Medical Chart Review of an Infliximab Infusion
Take the challenge. CPT codes: 96413, 96415, 96375, J1745x30, J1200x1 Diagnosis ICD-10: M05.79 With the total infusion time of two hours and 13 minutes, CPT code 96413 is used to code for the first hour of the infusion and 96415 for the additional hour. The infusion would have to be 31 minutes into the next…
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