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Q/A: What Diagnosis Codes Should I Use for TMJ Headache Massage for Coverage?
October 16th, 2018 - Wyn Staheli, Director of Research

Question: We have been receiving several DDS referrals to our massage therapists who do intra-oral work. The only problem is that the referral from the DDS lists code R51 for headaches as the only DX code. Since most plans don't cover massage therapy for headaches alone, are there any codes that can distinguish the headaches as ...

Q/A: What Codes do I use for CLIA-Waived Tests?
October 16th, 2018 - Wyn Staheli, Director of Research

Question: I am a certified DOT medical examiner and have applied to get my CLIA lab (waiver) for urinalysis, finger prick blood tests for A1c, cholesterol and glucose. I realize I cannot diagnose patients with these tests, but I am using them to make decisions in the DOT process and with ...

Pelvic Floor Dysfunction Treatment Coverage
October 16th, 2018 - Wyn Staheli, Director of Research

Pelvic floor dysfunction is often the underlying cause of conditions such as pelvic pain; urinary or bowel dysfunction; and/or sexual symptoms. Treatment generally begins with an evaluation and testing (e.g, EMG) followed by a variety of services (e.g., biofeedback, manipulation, pelvic floor electrical stimulation), depending on the findings. Coverage by payers ...

Prolonged Services Its Not Just About Time
October 5th, 2018 - BC Advantage

Time, as it applies to E/M codes, has often been viewed as an "if/then" proposition. "If" the documentation shows that a majority of the encounter was based on counseling and/or coordination of care, "then" we choose the highest level of service based on the total time of the encounter. However, a ...

HCC - Acceptable Provider Interpretation for Diagnostic Testing
October 1st, 2018 - Wyn Staheli, Director of Research

The following table is taken from the Contract-Level Risk Adjustment Data Validation Medical Record Reviewer Guidance dated 2017-09-27 (see References). It is a listing of acceptable provider interpretation of diagnostic testing. Acceptable Examples include: Cardiology and Vascular Surgeons Echocardiogram (including Doppler, Duplex, Color flow of the heart vessels) EKG (electrocardiogram) – Stress test, Cardiac ...

Editors choice articles

HCC - Acceptable Provider Interpretation for Diagnostic Testing
October 1st, 2018 - Wyn Staheli, Director of Research

The Potential Impacts of a Flat Rate EM Reimbursement on our Industry
September 26th, 2018 - BC Advantage

The proposed E&M changes by CMS would decrease provider administrative work burden by, per CMS, 51 hours a year; however, how will reducing documentation requirements truly affect the professionals of the healthcare industry? First, let’s discuss the 30,000-foot overview of the most impactful E&M changes—which is the change to the...

Pricing for ASC’s and APC’s
August 27th, 2018 - Chris Woolstenhulme, QCC, CMCS, CPC, CMRS

For Medicare purposes, an Ambulatory Surgical Center Resources (ASC) is a distinct entity that operates exclusively to furnish surgical services to patients who do not require hospitalization and in which the expected duration of services does not exceed 24 hours following admission. ASC payment groups determine the amount that...

PSAVE Pilot Program - What Does it Mean to You?
August 20th, 2018 - Wyn Staheli, Director of Research

Noridian's pilot program Provider Self-Audit with Validation and Extrapolation (PSAVE) has been extended which means that it has been successful for the payer, which means that they are saving money. Historically, when a pilot program is proven to be successful, it isn’t too long before other MACs follow. Before signing up to participate, providers need to carefully evaluate the program. Are the benefits worth the costs?

When Medical Necessity and Medical Decision Making Don't Match
August 3rd, 2018 - BC Advantage

As coders and auditors, we are taught the documentation guidelines on how to determine medical decision making. However, Medicare is clear that medical necessity is what determines the overall payment. In order to know what to do when medical necessity and medical decision making do not line up, you must...