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Latest articles

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 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 ...
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...

Latest questions/posts

J0171 - Epinephrine Epi Pen - Help please
   Oct 19th, 2018 - Mand0984 11 

CPT code for nephrology capitation billing to arkansas Medicaid
   Oct 17th, 2018 - anitac

Outcome Assessment Tools
1st    Sep 14th, 2018 - DrEd

NHP-RI CPT 64450-XS denied as non coverd
   Sep 11th, 2018 - austin

Diabetic Foot Care
   Aug 28th, 2018 - alleegator13

Hiv - 2
1st    Aug 21st, 2018 - Jstew

MDM credit in Table B
   Aug 17th, 2018 - damills 1 

Grouping of mutually exclusive CPt4 in IR DRG
1st    Aug 17th, 2018 - Hhiba

Denial in question
   Aug 15th, 2018 - alleegator13

Incident To Billing
   Aug 14th, 2018 - dlstoner512 1 

Reimbursement Question for J2785 - Injection, regadenoson, 0.1 mg
1st    Aug 13th, 2018 - Jaywalkz

CPT 61510 and 61518- multiple tumors
   Aug 12th, 2018 - LBAROGIANIS 250 

ICD-10 - Help
   Aug 7th, 2018 - precod 10 

Repair Code vs Flap Code
   Aug 2nd, 2018 - sharris

Dexcom G5 CPT
   Jul 13th, 2018 - precod 10 

I need codes for private lab tests to report to Medicare and AARP
1st    Jun 28th, 2018 - maryaloftus

Rewording prior question on CPT 93000
   Jun 27th, 2018 - sschwartz 3 

Aetna denial on E/M codes
   Jun 27th, 2018 - gowri.tina

Pouchoscopy with dilation of anus with biopsy?
1st    Jun 25th, 2018 - mlh2000ku

VP tie off
   Jun 22nd, 2018 - lizzg


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