A recent study from the healthcare solutions company Premier indicated that $19.7 billion is what hospitals and health systems are spending annually on handling and appealing denials. Yes, that is…
The average cost of debunking a denial is $25 per claim, not to mention the continuous challenges associated with attaining timely payment. Reviewing denial management strategies on a regular basis…
Do you know what your practice’s clean-claims submission rate is? Because if it’s not currently 95% or above, you’ve got work to do. Claim rejections are costly. Anything lower than…
Dr. John Cullen's four-physician family medicine practice in Valdez, Alaska, employs three full-time staffers who work on insurance and patient billing. A fourth full-timer focuses on obtaining prior authorizations from…
A year after the much-hyped switch to the ICD-10 diagnostic coding library, healthcare providers now face pressures to assign codes with the right degree of specificity or risk claim denials.…
In the wake of the Oct. 1 transition to ICD-10, very few issues have surfaced. However, providers and billers have experienced difficulty with coding for medical necessity, receiving denials due…
On Thursday, CMS announced that about 10% of claims submitted since the Oct. 1 transition to ICD-10 have been rejected, but only a small percentage of those were denied because…
Healthcare providers will need a denials manager who can track denials and communicate with healthcare payers.
Here comes a late holiday gift for Part B practices. Thanks to a new transmittal on the topic, CMS has announced that MACs won’t institute ordering/referring PECOS edits until July.
Currently, if you submit claims for services or items ordered/referred and the ordering or referring physician’s information is not in the MAC’s claims system or in PECOS, your practice will get an informational message letting you know that the practitioner’s information is missing from the system. It was previously announced that MACs would start denying these claims on Jan. 3, but CMS announced on Dec. 16 that claim denials won’t begin until July 5.
In Part B, MACs will take two steps before denying your claims. First, the carrier will check whether the ordering/referring physician is in PECOS. If not, the MAC will try to find the provider in the Claims Processing System Master Provider File. If the physician is in neither system, the claim will be rejected starting this July.
Even though CMS won’t reject your claims this month, you should still take this time to ensure that you and your ordering/referring providers are in PECOS as soon as possible, just in case the MAC edits become a reality, said National Government Services’ Andrea Freibauer during a Nov. 9 webinar on ordered and referred services.
To read the updated CMS transmittal, visit http://www.cms.gov/transmittals/downloads/R825OTN.pdf.
Hospices benefited from a separate holiday gift that CMS delivered just before Christmas – a delay of the enforcement date for the new face to face encounter requirement.
For weeks, hospices, home care providers, and their representatives had been giving CMS the full court press about the burdensome new physician visit requirement. In a Dec. 15 letter to CMS Administrator Donald Berwick, more than 25 senior and long-term care organizations joined the National...
Medically unlikely edits ignorance could be causing you medical coding claim denials.
Ensure you’re not letting medically unlikely edits (MUEs) wreak havoc on your urology practice’s coding and reimbursement by uncovering the truth about four aspects of these edits.
Myth 1: MUE Edits Don’t Affect Your Practice
Some practices feel that they don’t need to worry about MUEs.
Reality: “They limit the frequency a CPT code can be used,” says Chandra L. Hines, business office manager at Capital Urological Associates in Raleigh, N.C. “With our specialty of urology, we need to become aware of the denials and not let every denial go because the insurance company said it was an MUE. We should all be aware of MUEs as they occur, and we cannot always control whether or not we will receive payment.”
The MUE list includes specific CPT or HCPCS codes, followed by the number of units that CMS will pay. CMS developed the MUEs to reduce paid claims error rates in the Medicare Program. The first edits were implemented in January 2007, although some of the edits themselves became public in October 2008.
Some MUEs deal with anatomical impossibilities while others edit automatically the number of units of service you can bill for a service in any 24-hour period. Still others limit codes according to CMS policy. For example, excision of a hydrocele, bilateral (55041) has a bilateral indicator of “2,” so you should never bill two or more units of this code. Additional edits focus on the nature of the equipment for testing, the study or procedure, or pathology specimen.
Anatomical example: The MUEs edit out and deny an erroneously coded claim for a circumcision (54161, Circumcision, surgical excision other than clamp, device or dorsal slit; older than 28 days of age) for a patient...
Don’t let ‘wrong surgery’ modifier mistakes stall your reimbursement.
You use modifier TC for the technical component of a test. So logically, you should use modifier PC for the professional component, right? Wrong. But many coders are making that mistake...