Category Archives: iMAX Medical Billing Insights

Prioritizing HIPAA Compliance Efforts

[lightbox link=”” thumb=”×218.png” width=”300″ align=”left” title=”lockedfile” frame=”true” icon=”image” caption=””]Risk analysis is crucial to assess your organization’s potential compliance vulnerabilities, threats, and risks to protected health information (PHI). To begin, you need to know how patient data flows within your organization. There are four main locations to consider Where PHI enters your environment: Identify all PHI inputs. What happens to PHI in your environment, including where it is stored: Does it go directly to accounting? Is it automatically stored in your EHR? If it is emailed, is it encrypted? Where PHI leaves your environment: If PHI leaves your organization, you must

Place of Service Coding

Place of Service Codes (POS) are two-digit codes reported on health care professional claims to indicate the setting in which a service was provided. Each billable line item should have a Place of Service Code listed to identify where the service was rendered. POS codes are listed in the front of the CPT® codebook, and are also available on the CMS website. Improper application of POS codes can affect payments. As CMS Transmittal 2679 explains, “Under the Medicare Physician Fee schedule (MPFS), some procedures have separate rates for physicians’ services when provided in facility and nonfacility settings.” For this reason,

Medicare Provides Incentive to Talk About Death

No one wants to be the bearer of bad news, especially when it involves the death of someone you’re caring for. After all, it’s ingrained in provider ethics to save lives and to “be dedicated to providing competent medical care, with compassion and respect for human dignity and rights” (American Medical Association (AMA) Principles of Medical Ethics). That’s why end-of-life care is a tough pill to swallow not just for the patient, but sometimes for providers, as well. When many specialists are caring for the same patient, sometimes it’s unclear who should talk to patients about end-of-life care options. At times it’s so difficult, in fact, that The Atlantic

Amending the Medical Record

CMS is aware that amendments, corrections, and delayed entries occur in the medical record. Occasionally upon review, a provider may discover that certain entries, related to actions that were actually performed at the time of service, were not properly documented or entered after rendering the service. Whether a documentation submission originates from a paper record or an electronic health record, amendments, corrections, or addenda must: Clearly and permanently identify any amendment, correction, or delayed entry, as such. Clearly indicate the date and author of any amendment, correction, or delayed entry. Not delete, but instead clearly identify, all original content. “Timeliness”

“Reviewed” Not Sufficient Documentation

Documentation stating “Family History Reviewed” is insufficient to satisfy evaluation and management (E/M) documentation requirements. Both the 1995 and 1997 documentation guidelines specify, “A ROS and/or a PFSH obtained during an earlier encounter does not need to be re-recorded if there is evidence that the physician reviewed and updated the previous information. This may occur when a physician updates his or her own record or in an institutional setting or group practice where many physicians use a common record. Specifically, according to the documentation guidelines, the review and update may be documented by: Describing any new ROS and/or PFSH information

HPI Demonstrates Medical Necessity

Medical necessity is demonstrated based on information captured in the history of present illness (HPI). Documentation quality matters more than quantity. The information should be relevant to the presenting problem(s), and it should seek to answer the questions each HPI element asks, as follows: Location: e.g., Back pain, Nasal Congestion Quality: e.g., sharp or shooting pain, dry cough Severity: e.g., extremely nauseated, moderate pain Duration: e.g., Onset two weeks ago Timing: e.g., Worse in the mornings, Occurs constantly Context: e.g., Dizzy upon standing, Worse after excersice Associated Signs/Symptoms: e.g., a chief complaint of nausea may be accompanied by associated symptoms

OIG Continues to Focus on POS Errors, and So Should You

Once again, the OIG has included place of service (POS) errors as a focus of its annual Work Plan: We will review physicians’ coding on Medicare Part B claims for services performed in ambulatory surgical centers and hospital outpatient departments to determine whether they properly coded the places of service. Context—Prior OIG reviews determined that physicians did not always correctly code nonfacility places of service on Part B claims submitted to and paid by Medicare contractors. POS errors are more than “clerical.” As the work plan explains, “Medicare pays a physician a higher amount when a service is performed in

Services You Should Never Code Separately

Medicare bundles (includes without separate payment) certain services and supplies when they are provided with other, more comprehensive services. According to the National Correct Coding Initiative (NCCI), Chapter 1 (General Correct Coding Policies): Examples of services integral to a large number of procedures include: – Cleansing, shaving and prepping of skin – Draping and positioning of patient – Insertion of intravenous access for medication administration – Insertion of urinary catheter – Sedative administration by the physician performing a procedure – Local, topical or regional anesthesia administered by the physician performing the procedure – Surgical approach including identification of anatomical landmarks,

Modifier 22: Difficult Isn’t Enough

Difficulty alone doesn’t justify appending modifier 22 Increased procedural services. The procedure must be unusually difficult in relation to other procedures of the same type. The values assigned to CPT® codes assume an “average” service. Only rare, outlying cases—those that are far beyond the average difficulty—call for modifier 22. The AMA’s CPT Changes 2008 explains, “This modifier should be used only when additional work factors requiring the physician’s technical skill involve significantly increased physician work, time, and complexity than when the procedure is normally performed.” Most commonly, modifier 22 will accompany surgical claims—although modifier 22 also might apply to anesthesia

New Reporting Requirements for Labs will Determine Future Payments

[lightbox link=”” thumb=”×218.jpg” width=”300″ align=”left” title=”cms” frame=”true” icon=”image” caption=””]The Centers for Medicare & Medicaid Services (CMS) released, Sept. 25, a proposed rule that will significantly revise the Medicare payment system for clinical diagnostic laboratory tests (CDLTs) and advanced diagnostic laboratory tests (ADLTs) paid under the Clinical Laboratory Fee Schedule (CLFS) beginning in 2017. The new payment system will base payments on a weighted median of private payer rates, as reported by certain laboratories during a specified period. Method for Calculating Payments Federal law limits the reduction in payment amounts that may result from implementation of a new payment methodology within