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How to Document and Bill Care Plan Oversight Services Care Plan Oversight (CPO) refers to a physician or allowed nonphysician practitioner's (NPP’s) supervision of patients under care of home health agencies or hospices who require complex or multidisciplinary care modalities. Nurse practitioners, physician assistants and clinical nurse specialists practicing within the scope of state law may bill for care plan oversight. Note: Such services are not covered for patients of skilled nursing facilities (SNFs), nursing home facilities or hospitals. Implicit in the concept of CPO is the expectation that the physician or NPP has coordinated an aspect of the patient’s care with the home health agency or hospice during the month for which CPO services were billed. The practitioner who bills for CPO must be the same practitioner who signs the plan of care. HCPCS Codes and Billing: G0179: M.D. recertification Home Health Agency (HHA) PT G0180: M.D. certification HHA patient G0181: Home health care supervision G0182: Hospice care supervision How to Submit a Claim: ◦ Providers billing CPO must submit the claim with no other services billed on that claim and may bill only after the end of the month in which the CPO services were rendered ◦ Do not bill CPO services across calendar months and should be submitted (and paid) only for one unit of service ◦ Submit CPT codes 99202–99263 and 99281–99357 only when there has been a face-to-face meeting/encounter ◦ Dates of service: For HCPCS codes G0181 and G0182, submit the first and last dates during which documented care planning services were actually provided during the calendar month ◦ Report care planning only once per calendar month ◦ Dates of service: For HCPCS codes G0179 and G0180, submit the date physician signed the certification or recertification ◦ HCPCS code G0179 may be reported only once every 60 days, except in the rare situation when the patient starts a new episode before 60 days elapses and requires a new plan of care to start a new episode ◦ Submit HCPCS code G0180 when the patient has not received Medicare covered home health services for at least 60 days. The initial certification (HCPCS code G0180) cannot be filed on the same date of service as the supervision service Documentation: ◦ Claims for care plan oversight services will be denied when review of the beneficiary’s claim history fails to identify a covered physician service requiring a face-to-face encounter by the same physician during the six months preceding the provision of the first care plan oversight service Medical records for these services must indicate: ◦ The physician spent 30 minutes or more for countable care planning activities ◦ The specific service furnished, including the date and length of time 👉Visit my profile for more updates #medicalcoding #hhc #careplanoversight #ptcareathome #homehealthcertification #documentation #billingandreimbursement

Billing Prolonged Services in 2024 CPT add-on codes +99417 and +99418 describe prolonged services with or without direct patient contact on the date of an E/M service in the outpatient or inpatient setting, respectively. You will use these codes to report additional time a healthcare provider spends beyond the total time requirement for the highest-level primary E/M service within the category. Do not include the time spent on clinical staff services when reporting an E/M or prolonged service by time. Remember the provider must spend at least 15 minutes beyond the total time indicated for the E/M services code before prolonged services can be billed. For instance, reporting the initial unit of a prolonged service code for a new patient office or other outpatient encounter (e.g., 99205) is appropriate only after accumulating at least 15 minutes of time beyond 60 minutes (i.e., a total of 75 minutes) on the encounter date. Similarly, for an established patient office or other outpatient encounter (e.g., 99215), reporting a prolonged service code is permissible once at least 15 minutes have been accrued beyond 40 minutes (i.e., a total of 55 minutes) on the encounter date. This extra time is often spent in direct patient care or managing complex cases. When using time for E/M level selection, the total time is the sum of the time personally spent by the physicians and qualified healthcare professionals in assessing/managing the patient and providing counseling, education, or test results to the patient/family/caregiver on the encounter date. Factor distinct time only; if multiple reporting individuals are involved, count the time of only one reporting individual. CPT 2024 Professional includes a table (see Table A 👇👇) that leaves no room for misinterpreting when prolonged services begin. #stayconnected #stayupdated #prolongedservices #cpt #addoncodes #medicalcoding #guidelines #codingtips #documentation #additionaltimespent

Attention to healthcare providers: Maximize your revenue collections by using Advance Beneficiary Notice (ABN) The rules enable you to bill Medicare patients when Medicare will not pay because it determines a service is not medically necessary. An Advance Beneficiary Notice, sometimes called an Advance Beneficiary Notice of Noncoverage (ABN), is issued by medical providers to beneficiaries of Medicare and lets them know what services might not be covered under it. The Centers for Medicare and Medicaid Services (CMS) sets guidelines for the use of an ABN. One of them is that Medicare may reimburse health-care providers and suppliers only for procedures and equipment that are medically necessary. In a situation where a patient has requested, or a provider has recommended, a procedure that may be deemed to be medically unnecessary, the ABN is used to notify the Medicare beneficiary (the patient) of the likelihood that Medicare will deny the claim, and the patient will be responsible for the full cost of the care provided. All healthcare providers and suppliers must complete an ABN if they would like to transfer financial liability to the Medicare beneficiary, with delivery of the notice prior to providing the items or services that are the subject of the notice. In addition, the ABN must be: • Reviewed with the beneficiary, with all beneficiary questions answered before signing • The ABN must be delivered far enough in advance that the beneficiary has time to consider the options and make an informed choice • The ABN must be completed and produced on a single page • All blanks must be completed, the form signed, and a copy provided to the beneficiary • The notifier must retain a copy of the ABN on file #stayconnectedstayupdated >>>> Visit my profile for more updates!! #medicare #abn #cms #claimprocessing #abnmodifiers #noncoverage #appeal

Significance of MUE and MAI in claim processing Medically Unlikely Edits (MUEs) are used by the Medicare Administrative Contractors (MACs), including Durable Medical Equipment (DME) MACs, to reduce the improper payment rate for Part B claims. Understanding why Medically Unlikely Edits (MUEs) were established, how they are organized, and the criteria on which edit rationales are based may help medical coders and billers avoid denials or, at a minimum, properly resolve a denial. An MUE for a HCPCS/CPT code is the maximum units of service (UOS) that a provider would report under most circumstances for a single beneficiary on a single date of service. Not all HCPCS/CPT codes have an MUE. To determine the maximum UOS a provider would report under most circumstances for a single beneficiary on a single date of service: -Select the appropriate quarterly edit date. -Enter the CPT/HCPCS code. -Click Search. -If CMS has a published MUE for the CPT/HCPCS code, the following will display: Effective date of the quarterly edits selected The MUE value (the maximum unit of service reported under normal circumstances) MUE Adjudication Indicator (MAI) (the type of MUE) MUE Rationale (the underlying basis for each MUE) MUE Adjudication Indicator (MAI) The MAI provides the rationale for the edit. MAI 1: Claim Line Edit. You may add a modifier to bill the same code on separate lines of a claim to identify additional medically necessary units over the MUE value. MAI 2: Absolute Date of Service Edit. These are "per day" edits based on policy. CGS will not pay in excess of the MUE value. MAI 3: Date of Service Edit. These are "per day" edits based on clinical benchmarks. CGS may pay over the MUE value at the appeals (Redetermination) level if there is adequate documentation of medical necessity to support additional units. #stayconnectedstayupdated >>>> Visit my profile for more updates!! #cms #mue #mai #claimedits #multipleunits #cpt #hcpcs #codingtips

NCCI: National Correct Coding Edits The Centers for Medicare & Medicaid Services developed the National Correct Coding Initiative (CCI) as a tool for preventing the overpayment of duplicative or overlapping fee schedule services. There are two basic types of code edits: the Correct Coding Initiative (CCI), and the Medically Unlikely Edits (MUE). Each performs a different function. 1) Correct Coding Initiative (CCI) The CCI edits prevent improper payment when incorrect code combinations are reported. Many of the CCI edits are based on the standards of practice. The CCI contains two tables of edits. CMS refers to these as: 1.a) Column One/Column Two Correct Coding Edits Table Services that are integral to another service are component parts of the more comprehensive service. When integral component services have their own HCPCS/CPT codes, CCI edits place the comprehensive service in Column One (payable) and the component service in Column Two (nonpayable). For example, if a patient undergoes a colonoscopy with a biopsy, the codes for the colonoscopy and the biopsy should be bundled together and billed as a single code. 1.b) Mutually Exclusive Edits Table The CCI Mutually Exclusive Code Edits include those codes that cannot reasonably be performed in the same session. For example, if a patient undergoes a knee replacement surgery, the codes for a knee arthroscopy and a knee arthroplasty cannot be billed together because they are mutually exclusive procedures. 2) Medically Unlikely Edits (MUE) Medically Unlikely Edits (MUE) were developed by CMS to reduce its contractors’ error rate on paid Part B claims. An MUE for a CPT code is the maximum units of service that a provider would report — under most circumstances — for a single beneficiary on a single date of service. Unlike the CCI edits, an MUE edit involves only one code — not a combination of two codes. Many of the CCI edits are constructed in a way that they can be overridden by appropriate use of a modifier. Modifier-59 (distinct procedural service) can be used with the edits. An update of the CCI edits is published every quarter. While coding multiple procedures, every coders must have access to the CCI edits tool to ensure coding is appropriate. >>>>Check out my profile to see more updates. #stayconnectedstayupdated #medicalcoding #cci #cciedits #bundledservice #column1column2 #modifier25 #codify

How to prevent coding denials in healthcare revenue cycle Preventing coding denials in the healthcare revenue cycle is crucial for ensuring accurate billing and timely reimbursement. Coding denials can occur due to various reasons, including incorrect diagnosis and procedure codes, lack of documentation, and coding guideline non-compliance. Here are some steps to help prevent coding denials 1) Hire and Train Competent Coders Employ certified medical coders with a strong understanding of ICD-10, CPT, and HCPCS coding systems. Provide ongoing training and education to keep coders up-to-date with the latest coding guidelines and updates. 2) Regular Coding Audits Conduct regular internal coding audits to identify and correct coding errors before claims are submitted. Use coding audit findings to provide feedback and training to coding staff/practice. 3) Documentation Improvement Collaborate with healthcare providers to improve clinical documentation quality. Ensure that medical records accurately reflect the patient’s condition, procedures performed, and medical necessity. 4) Coding Guidelines Compliance Stay updated with the latest coding guidelines and policies issued by CMS and other relevant authorities. Ensure that coders adhere to these guidelines in code selection and assignment. 5) Code Validation Tools Implement coding validation software or tools that can help coders identify potential coding errors in real-time. These tools can prompt coders to double-check and correct any discrepancies. 6) Regular Provider Training Conduct training sessions for healthcare providers to educate them about coding requirements and the impact of accurate documentation on revenue. 7) Pre-submission Reviews Perform a pre-submission review of claims to verify that codes are accurate and supported by appropriate documentation. Correct any errors or discrepancies before sending claims to payers. 8) Denial Analysis and Feedback Analyze denial trends to identify common coding-related issues. Use this data to provide feedback to coding staff and implement process improvements. 9) Utilize Coding Resources Utilize coding resources, such as coding books, coding software, and coding associations, to support accurate code assignment. 10) Stay Informed About Payer Policies Regularly check payer websites and resources to stay informed about specific coding and documentation requirements for each insurance company. Establish open lines of communication with payers to clarify coding and billing requirements. By implementing these strategies, healthcare organizations can reduce the likelihood of coding denials, improve revenue, and ensure compliance with coding and billing regulations. #codingtips #denials #denialcoding #claimresolution #revenuecycle #medicalcoding #providertraining #analysis #regulations

Transitional Care Management What is Transitional Care Management (TCM)? Transitional Care Management (TCM) services address the hand-off period between the inpatient and community setting. After a hospitalization or other inpatient facility stay (e.g., in a skilled nursing facility), the patient may be dealing with a medical crisis, new diagnosis, or change in medication therapy. Family physicians often manage their patients’ transitional care. TCM Coding The two CPT codes used to report TCM services are: CPT code 99495 – moderate medical complexity requiring a face-to-face visit within 14 days of discharge CPT code 99496 – high medical complexity requiring a face-to-face visit within seven days of discharge Requirements and Components for TCM -Contact the beneficiary or caregiver within two business days following a discharge. -The contact may be via telephone, email, or a face-to-face visit. Attempts to communicate should continue after the first two attempts in the required business days until successful. -Conduct a follow-up visit within 7 or 14 days of discharge, depending on the complexity of medical decision making involved. The face-to-face visit is part of the TCM service and should not be reported separately. -Medicine reconciliation and management must be furnished no later than the date of the face-to-face visit. -Obtain and review discharge information. -Review the need for diagnostic tests/treatments and/or follow up on pending diagnostic tests/treatments. -Educate the beneficiary, family member, caregiver, and/or guardian. -Establish or re-establish referrals with community providers and services, if necessary. -Assist in scheduling follow-up visits with providers and services, if necessary. Discharge from any of the following: Inpatient acute care hospital Long-term acute care hospital Skilled nursing facility/nursing facility Inpatient rehabilitation facility Hospital observation status or partial hospitalization Health Care Professionals Who May Furnish and Bill TCM Services: Physician (any specialty) Clinical nurse specialist (CNS) Nurse practitioner (NP) Physician assistant (PA) Certified nurse midwife Non-physicians must legally be authorized and qualified to provide TCM services in the state in which the services are furnished. https://lnkd.in/dK5Z54XE #tcm #transitionalmanagementcare #caremanagement #medicalcoding #guidelines #codingtips #codingandbilling

Time based E/M Coding: Total time on the date of the encounter may be used alone to select the appropriate code level for the following E/M services: Office visit services (CPT codes 99202-99205, 99211-99215) Inpatient and observation care services (CPT codes 99221-99223, 99231-99233) Hospital inpatient or discharge services (CPT codes 99234-99236, 99238-99239) Consultation services (CPT codes 99242-99245, 99252-99255) Nursing facility services (CPT codes 99304-99306, 99307-99310, 99315-99316) Home or residence services (CPT codes 99341-99345, 99347-99350) Time cannot be used to select the level of service for emergency department visits. The level of service is based on MDM. This does not differ from the previous guideline. However, the MDM levels have been modified to align with those for office visits (see below). Time may be used to select the level of service regardless of whether counseling dominated the encounter. The definition of time consists of the cumulative amount of face-to-face and non-face-to-face time personally spent by the physician or other QHP in care of the patient on the date of the encounter. It includes activities such as: Preparing to see the patient (e.g., review of tests); Obtaining and/or reviewing separately obtained history; Ordering medications, tests or procedures; Documenting clinical information in the electronic health record (EHR) or other records; and Communicating with the patient, family, and/or caregiver(s). Time spent in activities normally performed by clinical staff (e.g., time spent by nursing or other clinical staff collecting a patient’s history) should not be counted toward total time. Furthermore, time spent on a date other than the date of service should not be counted toward total time. For example, completing documentation on the day after the encounter would not be counted toward the total time when selecting the level of service for the encounter. Finally, time spent on services that are separately reportable (e.g., independent interpretation and reporting of test results, tobacco cessation counseling) should not be included in total time calculations. Each code has a specific time range. Physicians should ensure they document the total time spent on the date of the encounter in the patient’s medical record. Physicians should avoid documenting using time ranges and instead document specific total time spent on activities on the date of the encounter. #enmcoding #timebased #emlevel #mdm #medicalcoding #ushealthcare #rcm

What is Medicare Advance Care Planning (ACP)? Advance care planning (ACP) is the face-to-face time a physician or other qualified health care professional spends with a patient, family member, or surrogate to explain and discuss advance directives. CMS clarifies advance care planning coding and billing requirements: The Centers for Medicare & Medicaid Services (CMS) has revised its advance care planning (ACP) fact sheet to clarify the documentation and time requirements for this service. It highlights the following points. 1. Documentation of ACP discussions must include the following: [] The voluntary nature of the visit, [] The explanation of advance directives, [] Who was present (the patient, family member, caregiver, or surrogate), [] The time spent discussing ACP during the face-to-face encounter, [] Any change in health status or health care wishes if the patient becomes unable to make health decisions 2. ACP services are time based and subject to CPT rules such as the following: [] Time spent on other services performed concurrently (e.g., active management of a patient’s issues) does not count toward time spent on ACP, [] CPT code 99497 covers the first 30 minutes while code 99498 covers each additional 30 minutes, [] ACP discussions of 15 minutes or less cannot be billed as ACP services but can be billed as a different E/M service (e.g., an office visit) if the other service’s requirements are met, [] A unit of time is billable when the time spent passes the midpoint (e.g., 16-45 minutes would be 1 unit of 99497, 46-75 minutes would be 1 unit of 99497 and 1 unit of 99498, and 76-105 minutes would be 1 unit of 99497 and 2 units of 99498). Other changes to the fact sheet include adding the following: [] Medical orders for life-sustaining treatment and psychiatric advance directives as examples of advance directives, [] Payment information for Federally Qualified Health Centers and Rural Health Clinics. For more information, see the following resources: https://lnkd.in/dvjjQab4 #medicalcoding #advancecareplanning #acp #codingtips #guidelines #billingandreimbursement

How to Use Modifier 25 Questions about modifier 25 have increased since add-on code G2211 was implemented in 2024 to reflect the value primary care physicians provide to patients. Learn how to report modifier 25 correctly so that you can get paid accurately. What is modifier 25? Modifier 25 is a way to identify a “significant, separately identifiable evaluation and management service by the same physician or other qualified health care professional on the same day of the procedure or other service,” according to the CPT 2024 code set. Modifier 25 may only be appended to evaluation and management services. When can it be used? The E/M service must be significant and distinct from the procedure. The E/M must reflect work that is above and beyond the usual work associated with the procedure or other service. Asking the following questions can help determine whether it is appropriate to use modifier 25: ✔️ Did you perform and document the key components of a problem-oriented E/M service for the complaint or problem? ✔️ As documented, could the E/M service stand alone as a billable service? ✔️ Is there a different diagnosis for this portion of the visit? ✔️ If the diagnosis will be the same, did you perform extra physician work that went above and beyond the work of the other service or the typical pre- or postoperative work associated with the procedure? Modifier 25 should not be used when: ❌ The sole purpose of the encounter is for the procedure (e.g., lesion removal), and there is no documented medical necessity for a separate E/M service. The decision to perform a minor procedure is included in the payment for the procedure and should not be reported as a separate E/M service. Example: Visit for lesion removal A patient presents to have a mole assessed and the physician decides to remove it. The decision to remove the mole is included in the procedure code and should not be billed as a separate E/M service. However, in this same scenario, if the mole has a suspicious, potentially malignant appearance that the physician relates to the patient, in a separate identifiable E/M service, and discusses the possible need for a more extensive procedure if the pathology report comes back positive for malignancy, the E/M visit would be reported with a 25 modifier, along with the procedure code for the lesion removal. https://lnkd.in/dgr3MHNT #medicalcoding #modifiers #modifier25 #enm #stayconnected #stayupdated