Doris V. Branker, CPC, CPC-I, CEMC
|
|
- Candace Campbell
- 6 years ago
- Views:
Transcription
1 Doris V. Branker, CPC, CPC-I, CEMC 1
2 Identify the common sources for missed reimbursement in the specialty practice Identify the common sources for reduced reimbursement in the specialty practice Identify common compliance risks for the specialty practice 2
3 Revenue from procedures typically represent a greater portion of reimbursement Scope of practice is more targeted Risk of financial provider liability is greater Capitation is less common 3
4 Part I 4
5 Demographic data collection and maintenance Insurance verification for all lines of business in the practice Program specific payer data (Humana HMO vs. Humana Medicare)** This is the ideal point for collection of this data 5
6 Not knowing payerspecific contract rates prevents Collection of accurate TOS money Identification of inappropriate payments Ability to make financially viable decisions* $$$ 6
7 Lack of knowledge of contract data prevents Adherence to payer/subpayer timeliness guidelines Early identification of payer specific issues and trends Escalation Process Know your state laws!!! Missed charges Internal controls Adjustment tracking and policies Timely correction of internal/external errors Reporting 7
8 Based on type of service: Copayments Coinsurances Vital for surgical practices Deductibles Non-covered Services Verification process should capture practice service level detail including: TOS/POS Office based surgery Ancillary services Imaging services 8
9 Non-covered services Advanced notification to patients Alternate codes for reporting of services Correct by CPT/ICD but incorrect based on payer written specifications Methodology for reporting modifiers Misreporting of packaged services Surgical package varies 9
10 Medications/Supplies Billing for fewer units of services than documented Not billing for administered medications Lack of reconciliation for all rendered services Surgical Schedule Office schedule Hospital call services* 10
11 Lack of resources Provider specialty board memberships AMA only LCD/NCDs Coding programs Medical society positions Use of outdated references/resources Manuals Provider bulletins Coverage Policies 11
12 12
13 Misuse of modifiers* No knowledge of payer specific coverage policies Over-collection of TOS money based on billed rates Mid-level practitioner billing* Lack of internal reviews Lack of external reviews (unbiased) HCPCS billing* New provider billing E/M Services* 13
14 Know when modifiers are applicable Ensure documentation and medical necessity supports the use Do not apply for claim payment purposes only Do not add modifiers upon verbal advice from insurance representatives without understanding Refer to payer-specific instruction when applying modifiers (if it exists) Have a thorough understanding of AMA/CPT direction and intention in absence of payer guidance 14
15 Global period may be 0-90 days based on procedure Minor- 10 days* Decision for surgery included in surgical procedure payment unless significant and separately identifiable Total of 11 days Day of surgery + 10 days following= Global Major- 90 days* Decision to perform surgery separately billable w/modifier -57 Total of 92 days Day before surgery + Day of Surgery + 90 days after surgery = Global 15
16 Reflects one of the following related to global days 000- Minor procedures or endoscopies 010- Minor procedures or endoscopies 090- Major surgeries YYY- refer to local carrier for number of global days if not listed ZZZ- refer to primary CPT for global days (add-on codes) 16
17 Modifier 24 Use on an E/M service that is unrelated to the problem warranting the surgical procedure in global period Should be used for complications that are addressed with an E/M service* Modifier 25 Use on an E/M service when E/M is separately identifiable from the other service or procedure performed on same day Carve out pre-procedure work and if remaining elements equate to a billable E/M service, report w/modifier 17
18 Type of service Consultation vs. Referral New vs. Established Incident to vs. Split/Shared Level of care assignment 18
19 New Patient Providers following individual self-created vs. CPT definition of new patient Consultations billed when new/established patients visits are more appropriate Beware of Medicare requirements for consultation reporting** Some Commercial Medicare products are following this guidance 19
20 Incident to Applies to services rendered by NPP Applicable to physicians office/clinic settings only Must be integral part of services provided by provider Requires direct supervision by a physician May be billed under physician s number w/no loss in reimbursement Split/Shared Applies to ED/Hospital setting Billed under NPP if physician has NO face-toface encounter w/patient Billed under physician if face-to-face encounter and co-signature is performed 20
21 Quantity of documentation does not justify higher level of service in absence of medical necessity Do not use coding tools without review and understanding of documentation guidelines Record cloning increases likelihood of over reporting Remove the $$$ from the decision on code level If reporting based on time ensure the documentation supports the details of counseling/care coordination 21
22 Coding of Evaluation and Management Services We will review evaluation and management (E&M) claims to identify trends in the coding of E&M services. Medicare paid $25 billion for E&M services in 2009, representing 19 percent of all Medicare Part B payments. Pursuant to CMS s Medicare Claims Processing Manual, Pub. No , ch. 12, , providers are responsible for ensuring that the codes they submit accurately reflect the services they provide. E&M codes represent the type, setting, and complexity of services provided and the patient status, such as new or established. We will review E&M claims to determine whether coding patterns vary by provider characteristics. Payments for Evaluation and Management Services We will review the extent of potentially inappropriate payments for E&M services and the consistency of E&M medical review determinations. CMS s Medicare Claims Processing Manual, Pub. No , Ch. 12, instructs providers to select the code for the service based upon the content of the service and says that documentation should support the level of service reported. Medicare contractors have noted an increased frequency of medical records with identical documentation across services. We will also review multiple E&M services for the same providers and beneficiaries to identify electronic health records (EHR) documentation practices associated with potentially improper payments. 22
23 In order to meet all the general requirements for coverage under the incident-to provision, an FDA approved drug or biological must: Be of a form that is not usually selfadministered; Must be furnished by a physician; and Must be administered by the physician, or by auxiliary personnel employed by the physician and under the physician s personal supervision. Must represent an expense to the physician 23
24 Should be monitored at intervals regardless whether process in internal/external Billing companies or housed billing Smaller practices have a higher probability of erroneous practices Lack of internal training Lack of resources Unskilled staff 24
25 /FY11_WorkPlan-All.pdf 25
Compliant Documentation for Coding and Billing. Caren Swartz CPC,CPMA,CPC-H,CPC-I
Compliant Documentation for Coding and Billing Caren Swartz CPC,CPMA,CPC-H,CPC-I caren@practiceintegrity.com Disclaimer Information contained in this text is based on CPT, ICD-9-CM and HCPCS rules and
More informationEVALUATION AND MANAGEMENT: GETTING PAID FOR WHAT YOU DO
EVALUATION AND MANAGEMENT: GETTING PAID FOR WHAT YOU DO Kim Huey, MJ, CHC, CPC, CCS-P, PCS, CPCO Sandy Giangreco, RHIT, CCS, CCS-P, CHC, CPC, COC, CPC-I, COBGC Agenda 2014 OIG Report CMS Documentation
More informationShared and Incident To Billing of E/M Services in Radiation Oncology Updated November 2017
ASTRO Guidance on Shared and Incident To Billing of Evaluation and Management Services in Radiation Oncology The Centers for Medicare and Medicaid Services (CMS) establishes Medicare policy for the payment
More informationCoding, Corroboration, and Compliance How to assure the 3 C s are met
Coding, Corroboration, and Compliance How to assure the 3 C s are met Sue Roehl, RHIT, CCS sroehl@eidebailly.com 701-476-8770 OIG 1996 - $23.2 Billion errors Figure 1 Insufficient/No documentation 46.76%
More information1:35. NPP April Young Medical Consulting, LLC. Non-Physician Practitioner Coding and Billing. Disclaimer
Non-Physician Practitioner Coding and Billing Jill Young - CPC, CEDC, CIMC, East Lansing, Michigan 1 Disclaimer This material is designed to offer basic information for coding and billing. The information
More information601-Audit Plan for Medicare s Shared Visit Rule
601-Audit Plan for Medicare s Shared Visit Rule Elin Baklid-Kunz, MBA, CPC, CCS Health Care Compliance Association 6500 Barrie Road, Suite 250, Minneapolis, MN 55435 888-580-8373 www.hcca-info.org Presentation
More informationPostoperative Sinus Endoscopy and/or Debridement Procedures
Manual: Policy Title: Reimbursement Policy Postoperative Sinus Endoscopy and/or Debridement Procedures Section: Surgery Subsection: None Date of Origin: 10/1/2009 Policy Number: RPM009 Last Updated: 7/3/2017
More informationSurgical Assistant DESCRIPTION:
Private Property of Florida Blue This payment policy is Copyright 2017, Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents w ithout the express w ritten permission
More informationIMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY
Global Surgery Policy Number GLS03272013RP Approved By UnitedHealthcare Medicare Committee Current Approval Date 04/09/2014 IMPORTANT NOTE ABOUT THIS REIMBURSEMENT POLICY This policy is applicable to UnitedHealthcare
More informationCare Plan Oversight Services and Physician Services for Certification
Education Makes the Difference Care Plan Oversight Services and Physician Services for Certification and Recertification of Medicare-Covered Home Health Services A CMS CONTRACTED INTERMEDIARY CARRIER The
More informationObjectives. Observation: Exploring the MOON and Charge Capture. Aurora Health Care 10/11/2016
Observation: Exploring the MOON and Charge Capture Lynn Sisler, Senior Director Case Management Manpreet Lehn, Manager Revenue Assurance Objectives Understand the CMS requirements for the Medicare Outpatient
More informationPayment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL
Payment Policy: High Complexity Medical Decision-Making Reference Number: CC.PP.051 Product Types: ALL Effective Date: 6/2017 Last Review Date: See Important Reminder at the end of this policy for important
More informationMid-Level Providers: What You Need to Know to Use Them Successfully in Your Practice
Mid-Level Providers: What You Need to Know to Use Them Successfully in Your Practice Presented by Sarah Reed, BSE. CPC Senior Managing Consultant Medical Revenue Solutions, LLC AAPC 2016 Disclaimer The
More informationPECULIARITIES OF BILLING AND CODING IN LTC OCTOBER 14, 2011
PECULIARITIES OF BILLING AND CODING IN LTC OCTOBER 14, 2011 PRESENTED BY ALVA S. BAKER, MD, CMD Maine Medical Directors Association Faculty Disclosures: Dr. Baker has disclosed that he has no relevant
More informationDocumentation Guidelines. Medication Therapy Management (MTM)
Documentation Guidelines Medication Therapy Management (MTM) Effective Date Revision Letter Applies To: FINAL A UNMMG 1.0 Purpose This document provides guidelines for Pharmacist Clinicians (PhC) and other
More informationSee the Time chapter for complete instructions regarding how to code using time as the controlling E/M factor.
2015 EM Survival Guides Chapter 1: Office or Other Outpatient Visit (99201-99215) You should apply 99201-99215 for E/M visits in the office or other outpatient setting. These codes distinguish between
More informationObservation Coding and Billing Compliance Montana Hospital Association
Observation Coding and Billing Compliance Montana Hospital Association Sue Roehl, RHIT, CCS sroehl@eidebaill.com 701-476-8770 IP versus Observation considerations Severity of patient s signs and symptoms
More informationMLN Matters Number: MM6740 Revised Related Change Request (CR) #: Related CR Transmittal #: R1875CP Implementation Date: January 4, 2010
News Flash Flu Season is upon us! CMS encourages providers to begin taking advantage of each office visit to encourage your patients with Medicare to get a seasonal flu shot; it s their best defense against
More informationJaci Johnson, CPC,CPMA,CEMC,CPC H,CPC I President, Practice Integrity, LLC Disclaimer
Advanced Evaluation and Management More than a roll of the dice? History Exam Medical Decision Making Jaci Johnson, CPC,CPMA,CEMC,CPC H,CPC I President, Practice Integrity, LLC jaci@practieintegrity.com
More informationGlobal Surgery Package
Private Property of Florida Blue. This payment policy is Copyright 2017 Florida Blue. All Rights Reserved. You may not copy or use this document or disclose its contents without the express written permission
More informationGeneral Documentation Compliance. Review for Provider Reappointment
U N C U H N E C A L H T E H A L C T A H R E C A S R Y E S T E M General Documentation Compliance Review for Provider Reappointment May 2018 Objectives 1 2 Review the principles of compliant billing and
More informationProlonged Services With Direct Face-to-Face Patient Contact Service (Codes ) (ZZZ codes)
30.6.15.1 - Prolonged Services With Direct Face-to-Face Patient Contact Service (s 99354-99357) (ZZZ codes) (Rev.1490, Issued: 04-11-08, Effective: 07-01-08, Implementation: 07-07-08) A. Definition Prolonged
More information9/11/15. Reimbursement for Non- Physician Providers Real Life Practice Objectives
Reimbursement for Non- Physician Providers Real Life Practice 2015 John F. Bishop, PA, CPC, CPMA, CGSC, CPRC AAPA National Chair Reimbursement and ICD-10 Work Groups Principle, John Bishop and Associates,
More informationElectronic Health Records - Advantages and Pitfalls of Documentation
Electronic Health Records - Advantages and Pitfalls of Documentation Kansas City, KS HCCA Regional Conference September 25, 2015 1:00 P.M. 2:00 P.M. Presented by: Cynthia A. Swanson, RN, CPC, CEMC, CHC,
More informationAdvanced Evaluation and. AAPC Regional Conference Chicago 10/27/12
Advanced Evaluation and Management AAPC Regional Conference Chicago 10/27/12 Jaci Johnson, CPC,CPMA,CEMC,CPC H,CPC I President, Practice Integrity, LLC jaci@practiceintegrity.com Disclaimer Information
More informationJill M. Young, CPC, CEDC, CIMC Young Medical Consulting, LLC East Lansing, MI 4883
Jill M. Young, CPC, CEDC, CIMC Young Medical Consulting, LLC East Lansing, MI 4883 This material is designed to offer basic information for coding and billing. The information presented here is based on
More informationCritical Care, Evaluation and Management Services (99291, 99292)
Manual: Policy Title: Reimbursement Policy Critical Care, Evaluation and Management Services (99291, 99292) Section: Evaluation & Management Services Subsection: None Date of Origin: 10/28/2014 Policy
More informationBilling and Coding Tidbits for Not Leaving $$ on the Table
Billing and Coding Tidbits for Not Leaving $$ on the Table Presented by Sarah Reed BSE, CPC, CPC-I Senior Managing Consultant Medical Revenue Solutions, LLC AAPC 2016 Presentation Objectives Review some
More informationCertified Ophthalmic Executive (COE) Review Day
Certified Ophthalmic Executive (COE) Review Day Compliance Plan & Chart Audits Financial Disclosure The instructor acknowledges a financial interest in the subject matter of this presentation. Presented
More informationCOMPLIANCE ALERT. Department Chairs, Compliance Leaders, and UFJPI Management
UNIVERSITY OF FLORIDA COLLEGE OF MEDICINE - JACKSONVILLE Office of Physician Billing Compliance 653-1 West 8 th Street, LRC-3 Jacksonville, Florida 32209 Phone: (904) 244-2158 Fax: (904) 244-5323 COMPLIANCE
More informationChronic Care Management. Sharon A. Shover, CPC, CEMC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky
Chronic Care Management Sharon A. Shover, CPC, CEMC 2650 Eastpoint Parkway, Suite 300 Louisville, Kentucky 40223 502.992.3511 sshover@blueandco.com Agenda Chronic Care Management (CCM) History Define Requirements
More informationCLINICAL MEDICAL POLICY
CLINICAL MEDICAL POLICY Surveillance of Implantable or Wearable Cardioverter Policy Name: Defibrillators (ICDs): Office, Hospital, Web, or Non-Web Based (L34087) Policy Number: MP-052-MC-KY Responsible
More informationUniCare Professional Reimbursement Policy
UniCare Professional Reimbursement Policy Subject: Global Surgery Policy #: UniCare 0012 Adopted: 07/15/2008 Effective: 08/01/2017 Coverage is subject to the terms, conditions, and limitations of an individual
More informationOutpatient Hospital Facilities
Outpatient Hospital Facilities Chapter 6 Chapter Outline Introduce students to 1. Different outpatient facilities 2. Different departments involved in the reimbursement process 3. The Chargemaster 4. Terminology
More informationAcromioclavicular Joint Billing
Acromioclavicular Joint Billing October 27, 2016 When our physician performs an injection into the acromioclavicular (AC) joint of a patient in the office, can we bill 20610 for a large joint arthrocentesis?
More informationEmpire BlueCross BlueShield Professional Commercial Reimbursement Policy
Subject: Global Surgery NY Policy: 0012 Effective: 10/01/2016 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria listed below.
More informationGlobal Surgery Fact Sheet
DEPARTMENT OF HEALTH AND HUMAN SERVICES Centers for Medicare & Medicaid Services Global Surgery Fact Sheet Definition of a Global Surgical Package This fact sheet is designed to provide education on the
More informationChronic Care Management (CCM): An Overview for Pharmacists. March Developed Through a Collaboration Among:
Chronic Care Management (CCM): An Overview for Pharmacists March 2017 Developed Through a Collaboration Among: Overview of CCM and Complex CCM Beginning January 1, 2015, the Medicare Physician Fee Schedule
More informationChronic Care Management Coding Guidelines Effective January 1, 2017
Capture Billing & Consulting, Inc. 25055 Riding Plaza, Suite 160 South Riding, VA 20152 (703) 327-1800 Chronic Care Management Coding Guidelines Effective January 1, 2017 The Centers for Medicare and Medicaid
More informationAnthem Blue Cross and Blue Shield Commercial Professional Reimbursement Policy
Subject: Global Surgery IN, KY, MO, OH, WI Policy: 0012 Effective: 01/01/2018 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria
More informationGlobal Days Policy. Approved By 7/12/2017
Global Days Policy Policy Number 2018R0005A Annual Approval Date 7/12/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS You are responsible for submission of accurate
More informationFroedtert Health Billing Compliance Policy. description. Policy Number. Supersedes. Purpose. Definitions
Froedtert Health Billing Compliance Policy description Hospital and Professional Billing Compliance Policy, Provider Billing, Provider Coding, Billable Providers, Billing Compliance, Compliance, Revenue
More informationProvider-Based RHC Billing June 8, 2018
Provider-Based RHC Billing June 8, 2018 Sharon Shover, CPC, CEMC 502.992.3511 Provider-Based RHC Billing Agenda RHC Encounters Payment for RHC Services Same Day Visits Revenue Codes CG Modifier & QVL Non-RHC
More informationIndependent RHC Billing Introduction Session 3 Spring, 2018
Independent RHC Billing Introduction Session 3 Spring, 2018 Contact Information Mark Lynn, CPA (Inactive) RHC Consultant Healthcare Business Specialists Suite 214, 502 Shadow Parkway Chattanooga, Tennessee
More informationPOLICY AND PROCEDURE
AND PROCEDURE NUMBER: 0020 PAGE NUMBER: 1 of 7 I. PURPOSE: To ensure compliance with Federal and State billing and documentation guidelines of all UMMG billing providers. II. SCOPE: University of Miami
More informationCotiviti Approved Issues List as of April 27, 2017
Cotiviti Approved Issues List as of April 27, 2017 Ambulatory Surgery Center (ASC); Outpatient Hospital 23 Inpatient Hospital 25 Inpatient Hospital; Inpatient Psychiatric Facility 27 Inpatient; Outpatient;
More information9/17/2018. Critical to Practices
Critical to Practices Provides: Reviewing quality of care provided to patients. Education to providers on documentation guidelines. Ensuring all services are supported, and revenue captured. Defending
More informationMedical Fee Schedule (MFS) Frequently Asked Questions (FAQs) General FAQs
Medical Fee Schedule (MFS) Frequently Asked Questions (FAQs) General FAQs 1. What is the Medical Fee Schedule (MFS)? The MFS is the schedule of maximum fees payable for scheduled medical services rendered
More informationFY 2014 Changes to Medicare Inpatient Admission and Reimbursement Standards: CMS s Two Midnight Rule and the Revised Part A to Part B Rebilling Policy
FY 2014 Changes to Medicare Inpatient Admission and Reimbursement Standards: CMS s Two Midnight Rule and the Revised Part A to Part B Rebilling Policy Mark Polston King & Spalding In Fiscal Year 2014,
More informationKANSAS MEDICAL ASSISTANCE PROGRAM. Fee-for-Service Provider Manual. Podiatry
Fee-for-Service Provider Manual Podiatry Updated 03.2014 PART II Introduction Section BILLING INSTRUCTIONS Page 7000 Podiatry Billing Instructions.................. 7-1 Submission of Claim..................
More informationIncident to Billing. Incident-To. Charla Prillaman, CPC, CPCO, CPMA, CPC-I,CCC, CEMC, CHCO Breakout B4, Friday, 9/7/12
Incident to Billing Incident-To SING REVENUES IN THE BUSINESS OFFICE Charla Prillaman, CPC, CPCO, CPMA, CPC-I,CCC, CEMC, CHCO Breakout B4, Friday, 9/7/12 Today s Objectives Increase understanding of the
More informationReimbursement for Anticoagulation Services
Journal of Thrombosis and Thrombolysis 12(1), 73 79, 2001. # 2002 Kluwer Academic Publishers, Manufactured in The Netherlands. Reimbursement for Anticoagulation Services Paul W. Radensky McDermott, Will
More informationTime-Based Coding. Agenda. AMA Time Rule Physical Medicine Services Anesthesia Evaluation and Management Services Mental Health Services 2016 Changes
Time-Based Coding Presented by: Mike Strong, SFM The Work Comp Experts Agenda AMA Time Rule Physical Medicine Services Anesthesia Evaluation and Management Services Mental Health Services 2016 Changes
More informationProviding and Billing Medicare for Chronic Care Management Services
Providing and Billing Medicare for Chronic Care Management Services (and Other Fee-For-Service Population Health Management Services) No portion of this white paper may be used or duplicated by any person
More informationRural Health Clinic Overview
TrailBlazer Health Enterprises Rural Health Clinic Overview Steven W. Mildward Published March 2012 108724 2012 TrailBlazer Health Enterprises /TrailBlazer. All rights reserved. Important The information
More informationCMS IPPS 2014 Final Rule: Physician Education on Observation Status and 2-Midnight Rule
CMS IPPS 2014 Final Rule: Physician Education on Observation Status and 2-Midnight Rule John Zelem, MD, FACS Executive Medical Director Audit, Compliance and Education (ACE) AHA Solutions, Inc., a subsidiary
More informationMedical Reimbursement Newsletter
Abbey & Abbey, Consultants, Inc. Medical Reimbursement Newsletter A Newsletter for Physicians, Hospital Outpatient & Their Support Staff Addressing Medical Reimbursement Issues December 2011 Volume 23
More informationInpatient Psychiatric Facility (IPF) Coverage & Documentation. Presented by Palmetto GBA JM A/B MAC Provider Outreach and Education September 7, 2016
Inpatient Psychiatric Facility (IPF) Coverage & Documentation Presented by Palmetto GBA JM A/B MAC Provider Outreach and Education September 7, 2016 1 Disclaimer This information is current as of August
More informationChronic Care Management INFORMATION RESOURCE
Contents Chronic Care Management INFORMATION RESOURCE Purpose... 1 What Is CCM?... 1 Background... 1 Initiating Visit and Person-Centered Plan... 2 Clinical Supervision... 2 Qualifications for Personnel
More information1/21/2011. Cindy C. Parman, CPC, CPC H Coding Strategies, Inc.
Cindy C. Parman, CPC, CPC H Coding Strategies, Inc. www.codingstrategies.com The format and/or content of this presentation is copyright 2011 by Coding Strategies, Inc. (CSI), Powder Springs, GA. This
More informationCognitive Emotional Social Behavioral functioning
TIP SHEET Health and Behavior Assessment and Intervention (HBAI) Services Coverage of Chronic Disease Self-Management Education Medicare and Medicare Advantage Purpose: The HBAI services are used to identify
More informationModifiers 80, 81, 82, and AS - Assistant At Surgery
Manual: Policy Title: Reimbursement Policy Modifiers 80, 81, 82, and AS - Assistant At Surgery Section: Modifiers Subsection: None Date of Origin: 1/1/2000 Policy Number: RPM013 Last Updated: 7/11/2017
More informationCompliance. TODAY June High-level stress: Remembering the first OIG Medicare Compliance Review an interview with Tessa Lucey.
Compliance TODAY June 2013 a publication of the health care compliance association www.hcca-info.org High-level stress: Remembering the first OIG Medicare Compliance Review an interview with Tessa Lucey
More informationOutpatient Observation Services
Outpatient Observation Services Presented by: Gina Hobert, MBA, CHC, CPC-I, CPMA, CEMC, CRC Sr. Manager, Baker Newman Noyes Definition MCR Benefit Policy Manual, CMS 100-02, Chapter 6, 20.6 A. Outpatient
More informationEvaluation and Management Services
Evaluation and Management Services Print 1. If a physician sees a patient in the morning and again in the afternoon for a new or worsened condition, do we report modifier 25 for the second visit? 2. When
More informationEmpire BlueCross BlueShield Professional Reimbursement Policy
Subject: Global Surgery NY Policy: 0012 Effective: 02/01/2014 05/31/2014 Coverage is subject to the terms, conditions, and limitations of an individual member s programs or products and policy criteria
More informationCloning and Other Compliance Risks in Electronic Medical Records
Cloning and Other Compliance Risks in Electronic Medical Records Lori Laubach, Partner, Moss Adams LLP Catherine Wakefield, Vice President, Corporate Compliance and Internal Audit, MultiCare 1 AGENDA Basic
More informationCMS Observation vs. Inpatient Admission Big Impacts of January Changes
CMS Observation vs. Inpatient Admission Big Impacts of January Changes Linda Corley, BS, MBA, CPC Vice President Compliance and Quality Assurance 706 577-2256 Cellular 800 882-1325 Ext. 2028 Office Agenda
More informationUnderstanding Balance Billing. A Primer for L.A. Care Contracted Providers
Understanding Balance Billing A Primer for L.A. Care Contracted Providers Purpose for this Training 1. With new managed care programs (i.e. Cal MediConnect, Covered California, PASC- SEIU), members and
More information8/28/2014. Compliance and Practical Challenges When Using Scribes: Just What the Doctor Ordered? Objectives of the Presentation
Compliance and Practical Challenges When Using Scribes: Just What the Doctor Ordered? Jerry Williamson MD. MJ. CHC. LHRM Objectives of the Presentation Definition of a Scribe Duties of a Scribe Regulatory
More informationMEDICAL POLICY No R1 TELEMEDICINE
Summary of Changes MEDICAL POLICY TELEMEDICINE Effective Date: March 1, 2016 Review Dates: 12/12, 12/13, 11/14, 11/15 Date Of Origin: December 12, 2012 Status: Current Clarifications: Deletions: Pg. 4,
More informationBecoming a Champion of Physician and Hospital Alignment: Focusing on Length of Stay, Discipline and Standards of Care
Becoming a Champion of Physician and Hospital Alignment: Focusing on Length of Stay, Discipline and Standards of Care Marc Tucker, DO Senior Director Audit, Compliance & Education AHA Solutions, Inc.,
More informationGLOBAL DAYS POLICY. Policy Number: SURGERY T0 Effective Date: January 1, 2018
GLOBAL DAYS POLICY UnitedHealthcare Oxford Reimbursement Policy Policy Number: SURGERY 011.37 T0 Effective Date: January 1, 2018 Table of Contents Page INSTRUCTIONS FOR USE... 1 APPLICABLE LINES OF BUSINESS/PRODUCTS...
More informationObservation Services Tool for Applying MCG Care Guidelines
In the event of a conflict between a Clinical Payment and Coding Policy and any plan document under which a member is entitled to Covered Services, the plan document will govern. Plan documents include
More informationCONTRACT YEAR 2011 MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE PLAN MODEL TERMS AND CONDITIONS OF PAYMENT
CONTRACT YEAR 2011 MEDICARE ADVANTAGE PRIVATE FEE-FOR-SERVICE PLAN MODEL TERMS AND CONDITIONS OF PAYMENT Table of Contents 1. Introduction 2. When a provider is deemed to accept Flexi Blue PFFS terms and
More informationTable of Contents. 1.0 Description of the Procedure, Product, or Service Definitions Hospice Terminal illness...
Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Definitions... 1 1.1.1 Hospice... 1 1.1.2 Terminal illness... 1 2.0 Eligibility Requirements... 1 2.1 Provisions... 1 2.1.1
More informationE/M Auditing: History is the Key
E/M Auditing: History is the Key By Brandi Tadlock CPC, CPC-P, CPMA, CPCO CPC, CPMA, CEMC, CPC-H, CPC-I SUMMARY Review the history component in your E/M documentation to make sure it tells the patient
More informationCotiviti Approved Issues List as of February 26, 2018
Cotiviti Approved Issues List as of February 26, 2018 All physician/npp specialties 32 Ambulance Providers 34 Ambulatory Surgery Center (ASC), Outpatient Hospital 38 Inpatient Hospital 40 Inpatient Hospital,
More informationAddressing Documentation Insufficiencies
Objectives Addressing Documentation Insufficiencies ICAHN June 9,2015 Glenn Krauss, BBA, RHIA, CCS, FCS, PCS,CCS-P, CPUR, C-CDI, CCDS, C- DAM Understand and appreciate physician frustrations with the EHR
More informationAuditing and Monitoring in Clinics and Physician Practices
Auditing and Monitoring in Clinics and Physician Practices Dawnese Kindelt, CPC System Compliance Director Clinics Catholic Healthcare West Health Care Compliance Association 6500 Barrie Road, Suite 250,
More informationCHRONIC CARE MANAGEMENT IMPLEMENTATION GUIDE
CHRONIC CARE MANAGEMENT IMPLEMENTATION GUIDE TABLE OF CONTENTS What is Chronic Care Management (CCM)?... 2 Why CCM?... 2 Clinician/Practice Benefits... 3 Patient Benefits... 4 What is Included in CCM?...
More informationMEDICAL POLICY No R2 TELEMEDICINE
Summary of Changes Clarifications: Page 1, Section I. A 6, additional language added for clarification. Deletions: Additions Page 4, Section IV, Description, additional language added in regards to telemedicine.
More informationAs The Code Turns A Day In The Life Of A Code. Disclaimer. Objectives 9/13/2013
As The Code Turns A Day In The Life Of A Code Yvonne D Dailey, CPC, CPC-I, CPB Susan Ward, CPC, CPC-H, CPC-I, CEMC, CPCD, CPRC Jaci Johnson, CPC, CPC-H, CPMA, CPC-I, CEMC Melody Irvine, CPC, CPMA, CPC-I,
More informationConquering Consults. Objectives. Kim Reid,, CPC,, CPC-I,, CEMC
Conquering Consults Kim Reid,, CPC,, CPC-I,, CEMC Objectives Clearing up p cons consult lt conf confusion sion Understanding the consult requirements How do we code/document now that Medicare no longer
More informationKANSAS MEDICAL ASSISTANCE PROGRAM. Provider Manual. Podiatry
Provider Manual Podiatry Updated 07/2012 PART II Introduction Section BILLING INSTRUCTIONS Page 7000 Podiatry Billing Instructions.................. 7-1 Submission of Claim.................. 7-1 7010 Podiatry
More informationBilling Policies and Procedures WVU Physicians of Charleston
Billing Policies and Procedures WVU Physicians of Charleston POLICY/PROCEDURE NO.: B-10 Date(s) of Revision: 10/10/08 Section: Chapter: Policy: Compliance Billing Teaching Physician Requirements Evaluation
More informationOptima Health Provider Manual
Optima Health Provider Manual Supplemental Information For Ohio Facilities and Ancillaries This supplement of the Optima Health Ohio Provider Manual provides information of specific interest to Participating
More informationPresented for the AAPC National Conference April 4, 2011
Presented for the AAPC National Conference April 4, 2011 Penny Osmon, BA, CPC, CPC-I, CHC, PCS Director of Educational Strategies - Wisconsin Medical Society penny.osmon@wismed.org CPT codes, descriptions
More informationHCCA South Central Regional Annual Conference November 21, 2014 Nashville, TN. Post Acute Provider Specific Sections from OIG Work Plans
HCCA South Central Regional Annual Conference November 21, 2014 Nashville, TN Kelly Priegnitz # Chris Puri # Kim Looney Post Acute Provider Specific Sections from 2012-2015 OIG Work Plans I. NURSING HOMES
More informationThe World of Evaluation and Management Services and Supporting Documentation
The World of Evaluation and Management Services and Supporting Documentation Presented by Cahaba Government Benefit Administrators, LLC Provider Outreach and Education May 14, 2009 Disclaimers Disclaimer
More informationHospital Refresher Workshop. Presented by The Department of Social Services & HP Enterprise Services
Hospital Refresher Workshop Presented by The Department of Social Services & HP Enterprise Services 1 Training Topics Provider Bulletins Outpatient Claim Billing Changes Explanation of Benefit Codes Web
More informationCore Services Provided in Federally Clinical Coverage Policy No: 1D-4 Qualified Health Centers and Amended Date: October 1, 2015 Rural Health Clinics
Qualified Health Centers and Amended Date: October 1, 2015 Rural Health Clinics Table of Contents 1.0 Description of the Procedure, Product, or Service... 1 1.1 Federally Qualified Health Centers... 1
More informationElectronic Medical Record (EMR) How to Audit the Risks. Schawn Pedersen, CPC, CPC-E/M Manager Moss Adams LLP
Electronic Medical Record (EMR) How to Audit the Risks Schawn Pedersen, CPC, CPC-E/M Manager Moss Adams LLP Health Care Compliance Association 6500 Barrie Road, Suite 250, Minneapolis, MN 55435 888-580-8373
More informationModifiers 58, 78, and 79 Staged, Related, and Unrelated Procedures
Manual: Policy Title: Reimbursement Policy Modifiers 58, 78, and 79 Staged, Related, and Unrelated Procedures Section: Modifiers Subsection: None Date of Origin: 9/22/2004 Policy Number: RPM010 Last Updated:
More informationPayment Policy: Visits On Same Day As Surgery Reference Number: CC.PP.040 Product Types: ALL Effective Date: 03/01/2018
Payment Policy: Visits On Same Day As Surgery Reference Number: CC.PP.040 Product Types: ALL Effective Date: 03/01/2018 Revision Log See Important Reminder at the end of this policy for important regulatory
More informationThe Business of Medicine
The Business of Medicine Coding as a profession Objectives How the coder fits in Hospital vs. physician services Hierarchy of providers Reimbursement aspects Payers Medical necessity ABN 1 Regulations
More informationObservation Care Evaluation and Management Codes Policy
Policy Number Observation Care Evaluation and Management Codes Policy 2017R0115A Annual Approval Date 3/8/2017 Approved By Reimbursement Policy Oversight Committee IMPORTANT NOTE ABOUT THIS You are responsible
More information3F Auditing Outpatient Surgical Services. Disclaimer. Agenda. 3F Auditing Outpatient Surgical Services November 2013
3F Auditing Outpatient Surgical Services 2013 Regional Conference Baltimore, MD November 18, 2013 presented by Sarah L. Goodman, MBA, CHCAF, CPC H, CCP, FCS All Rights Reserved Disclaimer Every reasonable
More informationCritical Care What Makes this so Difficult
Critical Care What Makes this so Difficult Presented by Angela Jordan, CPC Senior Managing Consultant AAPC National Advisory Board, Southwest September 2016 Disclaimer The speaker has no financial relationship
More informationOUTPATIENT DOCUMENTATION IMPROVEMENT
OUTPATIENT DOCUMENTATION IMPROVEMENT Pam Brooks, MHA, COC, PCS, CPC Coding Manager Wentworth-Douglass Hospital Dover NH Disclaimer This presentation is for general education purposes only. The information
More information