Medical Billing

Approved preventive health services with co insurance and Deductible waived. G0101 G0296 G0402 99406 99407 G0438 G0439 G0442 G0443 G0444 G0445 G0446 G0447 Q0091

What is MACRA ? MACRA stands for Medicare Access & CHIP Reauthorization Act 2015 : Three major steps : 1) Ending sustainable growth rate for determining Medicare payment for health care provider service 2) Making new framework for rewarding health care provider for giving better care not just more care 3) Combining our existing quality reporting program's in to one new system These proposed changes replace a patchwork system of Medicare reporting program's with a flexible system that allows you to choose two path of links quality of payments . MIPS - Merit based Incentive Payment System. It's a combination of PQRS, Value based payment modifier and EHR. APM  - Alternative Payment Model 2019 - 2024 Lump sum incentive amount, increased transparency of physician focused payment model. Starting 2026, offers some participating health care provider higher annual payment. SOCIAL SECURITY NUMBER REMOVAL INITIATIVE MACRA Requires us to remove SSN from all Medicare ca

Description for 1P: Medical reasons Guidelines for 1P Modifier: In general, PQRI quality measures consist of a numerator and a denominator that permit the calculation of the percentage of a defined patient population that receive a particular process of care or achieve a particular outcome. Where a patient falls in the denominator population but specifications define circumstances in which a patient may be excluded from the measure’s denominator population, CPT Category II code modifiers 1P, 2P, and 3P are available to describe medical, patient, or system reasons, respectively, for such exclusion CPT modifier 1P: the quality measure was not applied due to medical reasons This modifier is only valid with some measures This modifier may only be reported with the CPT Category II codes for quality measures. It does not apply to HCPCS codes for quality measures. Refer to each individual quality measure for specific indications for this modifier

Description for AQ: Physician providing a service in a health professional shortage area. Guidelines/Instructions for AQ: Submit HCPCS modifier AQ in the following instances: When you provide services in ZIP code area that does not fall entirely within a designated full county HPSA bonus area When you provide services in a ZIP code area that falls partially within a full county HPSA but is not considered to be in that county based on the USPS dominance decision When you provide services in a ZIP code area that falls partially within a non-full county HPSA When you provide services in a ZIP code area that was not included in the automated file of HPSA based on the date of the data run used to create the file When services are provided in areas that were eligible for the HPSA bonus on December 31 of the prior year but were not on the automated ZIP code list  Designated HPSAs change periodically, so it is important to verify that services fall in a HPSA before submitti

Description: HCPCS Modifier Q6 Services furnished by a locum tenens physician Guidelines/Instructions for Q6: Guidelines Submit HCPCS modifier Q6 to indicate that services were provided under a locum tenens arrangement. Locum tenens background: Physicians may retain substitute physicians to take over their professional practices when they are absent for reasons such as illness, pregnancy, vacation or continuing medical education These substitute physicians, known as 'locum tenens' physicians, generally have no practice of their own and move from area to area as needed The regular physician generally pays the substitute physician a fixed per diem amount. The substitute physician's status is that of independent contractor, rather than employee, and his/her services are not restricted just to the physician's office. Services of non-physician practitioners (e.g., CRNAs, NPs and PAs) may not be billed under the locum tenens or reciprocal billing reassig

Modifier 58, Staged or related procedure or services by the same Physician or other Qualified Health care Professional during the postoperative period. When to Use modifier 58 Modifier 58 is used to identify those situations when a procedure or services may be staged(planned). While a return to the operating room for a related procedure may be commonplace, a staged (planned) procedure or services may not be as routine. I will try to clarify the intent when to exactly use modifier 58 with the procedure code. As per the CPT coding guidelines, Modifier 58 is assigned for any subsequent procedure, Which is planned or has to be performed with the related original procedure. Following three key points should be remembered before appending modifier 58 to the procedure codes. Modifier 78 Unplanned return to the operating / procedure room by the same physician or other qualified health care professional following initial procedure for a related procedure during the postoperative pe

Effective with services rendered October 1, 2015 and later,  ALL  ambulance transports require dual diagnoses.  Providers should report the primary diagnosis as the most appropriate ICD-10 code that adequately describes the patient’s medical condition at the time of transport.   In addition, a secondary diagnosis must be reported which reflects the patient’s need for the ambulance service and ambulance personnel at the time of transport.   In order for claims to be processed and paid in a timely manner it is important that claims submitted for ambulance services contain both the primary and secondary diagnosis. Please refer to the Ambulance Local Coverage Article A54574 for a list of “suggested” ICD-10 codes that may be reported as a primary diagnosis. Please note that the list of diagnosis codes provided in A54574 is not an all-inclusive list. Other valid ICD-10 diagnoses codes that accurately describe the patient’s condition at the time of transport may be reported as a primary diag

Inpatient Hospital Payment Rate Impacted by the Consolidated Appropriations Act, 2016 On Friday, December 18, 2015, President Obama signed into law the Consolidated Appropriations Act, 2016.  Section 601, Modification of Medicare Inpatient Hospital Payment Rate for Puerto Rico Hospitals modifies the payment calculation with respect to operating costs of inpatient hospital services of a subsection (d) Puerto Rico hospital for discharges on or after January 1, 2016. CMS is currently revising the Inpatient Prospective Payment System (IPPS) FY 2016 Pricer to reflect the new payment calculation requirement.  The amount of the payment with respect to the operating costs of inpatient hospital services of a subsection (d) Puerto Rico hospital for inpatient hospital discharges on or after January 1, 2016, will be based on 0 percent of the applicable Puerto Rico percentage and 100 percent of the applicable Federal percentage. In addition, the IPPS FY 2016 Pricer will include conforming changes

Provider Enrollment Application Fee Amount for CY 2016 On December 3, CMS issued a notice: Provider Enrollment Application Fee Amount for Calendar Year 2016 [CMS–6066–N] ( http://go.usa.gov/ckj8Z ). Effective January 1, 2016, the CY 2016 application fee is $554 for institutional providers that are: Initially enrolling in the Medicare or Medicaid program or the Children's Health Insurance Program (CHIP)Revalidating their Medicare, Medicaid, or CHIP enrollmentAdding a new Medicare practice location This fee is required with any enrollment application submitted from January 1 through December 31, 2016.

New place of service 19 Effective 1st January 2016, a new place of service 19 is available to use. A portion of an off-compus hospital provider based department which provides diagnostic, therapeutic ( Both surgery and nonsurgical), and rehabilitation services to sick or injured persons who don't require hospitalization or institutionalization .