Health and Human Services (HHS) has recently announced they intend to convert a majority of Medicare payments from the current fee-for-service system to a model that focuses on performance-based measurements (alternative payment models) in the next three years. This is the first time in the history of the Medicare program that HHS has set definitive goals for alternative payment models and value-based payments.

Understanding HCC’s —what are HCC’s?

Current Procedural Terminology’s (CPT) new codes for 2015 have been released and are patiently waiting to be utilized. Being able to understand the new CPT codes and modifiers pertinent to your practice will help providers obtain the proper payment for services performed. Focusing on Evaluation and Management, below are highlights of code changes, new codes, and key modifiers that are available for use in 2015.

On October 31, 2014, the Centers for Medicare & Medicaid Services (CMS) released its Medicare Physician Fee Schedule (MPFS) updates for the 2015 implementation. Below are highlights of updates and deeper insights on what changes/updates/policy adjustments providers can expect in 2015. 

Effective January 1, 2015, the Centers for Medicare & Medicaid Services (CMS) will be implementing four new Healthcare Common Procedure Coding System (HCPCS) modifiers to help further define subsets of the -59 modifier.

Clinical laboratory test billing and payment. Beginning in Calendar Year 2014, payment for most laboratory tests, except for molecular pathology tests, will be packaged under the OPPS. The general rule for OPPS Hospital is laboratory test should be reported on a 13X type of bill.

·       In past years, the proposed PFS has focused on the rates for the upcoming year. This time, the proposed schedule has a more limited scope due to the Protecting Access to Medicare Act (PAMA) of 2014 — signed into law on April 1 – which provides for a 0% increase in fees for services rendered between January 1 and March 31, 2015. However, CMS announced a negative 20.9% update for the remainder of 2015 following the expiration of PAMA.

Sigh. A big red ‘DENIED’ shows up on your unlisted code claim… again. How frustrating! Not only have you already spent a lengthy amount of time combing through your provider’s surgical documentation & deeming that an unlisted code is appropriate, you now need to figure out why this unlisted code is being denied.  Does this scenario sound familiar? It probably does, as all seasoned medical coders have found themselves in a similar situation such as this before. If you’re looking to end the denial cycle of the unlisted code, keep reading for some tools and tips from a payor’s point-of-view that will help you get your claim paid the first time, every time!

The global surgical period is full of complexity with CMS guidelines and payers’ interpretation.  The relationship between services performed and use of modifiers in conjunction with correct coding per CCI can be quite tricky.   In recent years, it has become an area of scrutiny and audit focus as defined by the Office of Inspector General (OIG).  In a 2013 transmittal, the OIG issued the following directive, “We will review the appropriateness of the use of certain claims modifier codes during the global surgery period and determine whether Medicare payments for claims with modifiers used during such a period were in accordance with Medicare requirements. Prior OIG work found that improper use of modifiers during the global surgery period resulted in inappropriate payments.”

With all of the pressures of closing out one year and jumping into the next, sometimes it’s hard to stay up-to-date with all of the 2014 coding changes. If you are a Pain Management Clinic, did you realize that, 64613 and 64614 will no longer be valid for 2014?  Read on if you are experiencing claim denials as the new codes for 2014 have greater specificity between anatomy and medical necessity.