One of the complexities for medical practices is using time in CPT® coding. CPT® has long had a unit of time rule that a unit of time is met when the midpoint has passed. That is, you’ve reached an hour after 31 minutes. There are many CPT® codes that follow this mid-point time rule including […]
How Physician Services are Paid
Use the resources here to quickly educate new practitioners and staff about coding and reimbursement. You'll find explanations about code sets and compliance, about Medicare incident-to and shared services rules, and requirements for billing for services provided jointly between a resident and an attending.
Coding Principles for Practice Administrators | Webinar
Recorded: July 21, 2022
Administrators managing both fee-for-service and value based payment contracts must maximize revenue and minimize risk in coding for services performed in their practices. Administrators—who aren’t coders—can accomplish this through by knowing where to find definitive answers and how to assess citations and conflicting information that is presented. This webinar will provide a framework for administrators when they are called about to mediate coding disagreements within their practices.
Payment Denials for Unspecified Codes
From the day coders got their first glimpse at ICD-10 codes, the question went out in the land: “Will payers deny unspecified codes?” Recently, a client told me that she was seeing an increase in denials for unspecified codes from payers and I wanted to gather more information about that. Thank you to the 140 […]
How Old is Your Oldest CPT® Book
My, how CPT® has grown Thank you to everyone who completed our mission critical survey: how old is your oldest CPT® book and how many pages is it? Page down: a summary chart is below. First, some of you save everything. I’d love to see your office shelves. There are coders out there who have […]
Best Practices in Revenue Cycle Management | Webinar
Recorded October 21, 2021
Guest presenter Elizabeth Woodcock, DrPH, MBA, FACMPE, CPC
Medical practices face new risks and opportunities as changes to the healthcare marketplace ignite the pressure to strengthen revenue cycle management (RCM). In this webinar, speaker, author, and consultant Elizabeth Woodcock provides a roadmap to optimize your practice management system, prevent denials, and strengthen cash collections. Find out about initiatives you can implement immediately.
How Medical Practice Services are Paid | Webinar
Recorded May 20, 2021
The coding and reimbursement system is anything but simple. This webinar will explain how services are paid in fee-for-service medicine, and the use of CPT codes, HCPCS codes, ICD-10-CM codes, bundling, and payer policies. It is a broad overview aimed at describing “who makes up these rules” and where to look for definitive, citation-based answers.
CMS Update on Medical Record Documentation for E/M Services
The world as we knew it Both the 1995 and 1997 evaluation and management (E/M) documentation guidelines stated that ancillary staff could record a review of systems (ROS), and past medical, family, and social history (PFSH) in a patient record. The billing physician/NP/PA needed to document that that information had been reviewed and verified. Only […]
Non-Physician Practitioners in Nursing Facilities
Members can read more about nursing facility services here, and in Everyday Coding. Question: Can a physician assistant see patients in a nursing facility without a physician signing each encounter? How do we bill this? Can we do wellness visits in a nursing facility? Answer: A physician assistant or an advanced practice registered nurse may see […]
Coding Guide – How Physician Services are Paid
This is an essential resource for new physicians, non-physician practitioners, coders and billers and for managers who want to know just enough to manage. In addition to this billing guide, be sure to reference the helpful infographic and Betsy’s 15 minute video on the payment process.
Teaching Physician Rules – Evaluation and Management Services
CMS policy update: E/M services performed under the teaching physician rules Download this teaching physician rules quick reference sheet for a summary of the rules. The CMS rules got a major update with the April 26, 2019 Transmittal 4823. A transmittal is a communication from CMS to the Medicare Administrative Contractors. It is followed by […]
Physician Specialty Codes and Claims Processing
Specialty designation is determines how claims are processed for physician and non-physician practitioners in groups It is also important in crediting data using the E/M guidelines, developed in 2021 and expanded in 2023 When physicians enroll in Medicare, they self-elect their specialty designation. In the enrollment process, there are fields to indicate primary and secondary […]
Coding Guide – Medicare Incident-to and Shared Services
This in depth guide reviews the requirements for billing Medicare Incident-to and shared services including: when/where these services can be billed, which provider number to use, and documentation requirements.
Diagnosis Coding | Not Just for Claims Anymore
Physician claims are paid based on the fee schedule associated with the CPT® or HCPCS code that is submitted. Diagnosis coding can be a reason for a denial. Physicians use CPT® or HCPCS codes to tell the payer what was done (colonoscopy, office visit) and modifiers to describe special circumstances (assistant at surgery, bilateral procedure.) […]
Who is Responsible for Coding Physician Services? The Medical Provider or the Coder?
Legally, when a physician, physician assistant (PA) or nurse practitioner (NP) enroll in a Medicare, Medicaid or commercial insurance, the practitioner signs an agreement attesting that accurate claims will be submitted. Practitioners are responsible for claims submitted under their National Provider Identifier (NPI). CMS’s E/M guide says, When billing for a patient’s visit, choose codes […]
Billing Physician Services for Hospice Patients | Reference Sheet
Medical practices find the hospice modifiers confusing, and confusion leads to denials and payment delays. Use the decision trees below to help you determine if the service is separately billable once a patient has elected hospice and if so, how to bill it.
Teaching Physician Rules | Bedside Procedures
Question: Can an attending bill for a bedside procedure that a resident did without the attending being present? If so, is this billed at 85% like a PA or NP? If a PA or NP is overseeing a bedside procedure that a resident is preforming how is this billed (no attending is present at the […]
OB Coder Survey | Billing Extra Visits During Pregnancy
Thank you to the 63 generous coders and billers who answered my questions about billing extra OB visits during the maternity period. If we and our payers are following CPT® rules, these extra visits caring for a pregnant patient are separately billable. The editorial comments at the start of the Maternity Care and Delivery section […]
Dear Resident, Do you Understand Relative Value Units (RVUs)?
Measuring physician productivity with work RVUs: News flash! Physicians are more interested in medicine than coding. No doctor undertook the rigors of medical school in order to be an expert coder. But, when residency ends, some physicians will find themselves looking at employment contracts in which their compensation will be determined in part by productivity. […]
7 Sure Fire Ways to Owe the Government $4 million in Fines and Repayments | Coding Compliance
Most practices aren’t looking to pay the government any money in fines and repayment because of coding errors. Two recent OIG settlements described two practices that did just that. Most practices want to avoid this, of course, but some groups seem determined to achieve that outcome. In reviewing both of the settlements, there are some […]
This Practice Paid Medicare $4.48 Million
Do you sign up for email lists and then wonder why you did it? We all do, don’t we? But, one email I always read is from the Department of Justice that links to a description of actions, settlements and indictments related to health care billing and coding A few years ago, an Orthopedic practice […]
Teaching Physician Rules and Surgical Procedures
The teaching physician rules describe a payment method by which Medicare pays an attending physician or teaching physician for services performed jointly with an intern, resident, or fellow, in an approved graduate medical education program (GME). The teaching physician’s presence and participation is required. The rules regarding participation and documentation vary by the type of […]