The Centers for Medicare & Medicaid Services (CMS) has published several new proposed rules regarding Medicare payments for 2025. In addition to updating payment rates, there are a large number o...
https://icd10monitor.medlearn.com/understanding-the-compliance-risks-with-new-payment-rules/
The Centers for Medicare & Medicaid Services (CMS) has recently taken significant steps to enhance the Medicare Prescription Payment Plan by issuing final guidance and new model materials, follow...
At this point we probably shouldn’t be surprised by the Roberts Supreme Court’s willingness to eviscerate precedent in the name of strict textualism. On the heels of eliminating Chevron defer...
https://icd10monitor.medlearn.com/a-farewell-to-the-administrative-law-judges/
The 60-day Refund Rule, created by the 2010 Patient Protection and Affordable Care Act (PPACA), requires providers to report and return Medicare and Medicaid overpayments within 60 days of identi...
https://icd10monitor.medlearn.com/understanding-the-perils-of-the-60-day-refund-rule/
While CMS (the Centers for Medicare & Medicaid Services) usually releases new rules in the afternoon, on July 10 they chose to release the 2025 Outpatient Prospective Payment System (OPPS) Propos...
In a move to support individuals at high risk of suicide or overdose, the Centers for Medicare & Medicaid Services (CMS) is proposing changes in the payment structure and services to expand teleh...
Business Intelligence (BI) refers to the technology-driven process for analyzing data and presenting actionable information to help executives, managers, and other corporate end-users make inform...
https://icd10monitor.medlearn.com/understanding-business-intelligence-and-the-impact-of-ai/
The Centers for Medicare and Medicaid Services (CMS) has released a summary of each HCPCS Level II code application decision. The document is twenty-eight pages long and the link can be found in ...
https://icd10monitor.medlearn.com/get-ready-for-hcpcs-heres-an-update/
Can we report 93922 for an ABI as a stand-alone procedure?
https://icd10monitor.medlearn.com/cardiology-question-for-the-week-of-july-22-2024/
What codes are used for reporting EEGs that are routine and what is the recording minute range for 2024?
https://icd10monitor.medlearn.com/respiratory-question-for-the-week-of-july-22-2024/
What codes do we report for the technical component of flow cytometry tests for identifying a specific cell surface in 2024?
https://icd10monitor.medlearn.com/laboratory-question-for-the-week-of-july-22-2024/
If a patient has rheumatoid arthritis and comes in for a methotrexate injection, do we use the chemotherapy injection code?
https://icd10monitor.medlearn.com/general-question-for-the-week-of-july-22-2024/
A patient had two different gray-scale ultrasound exams (76536) completed at the same encounter; one for thyroid nodules and one to evaluate a soft-tissue lump on the patient’s jawline. Can we ...
https://icd10monitor.medlearn.com/radiology-question-for-the-week-of-july-22-2024/
I’ll start with a quote from Yogi Berra, who once said it’s “tough to make predictions, especially about the future.” As I speculated in February, the Chevron Doctrine is finally gone. Af...
https://icd10monitor.medlearn.com/chevron-gone-but-not-forgotten/
The Centers for Medicare & Medicaid Services has released the proposed rule for the 2025 Medicare Physician Fee Schedule, or MPFS, setting the stage for potential changes that could impact health...
How safe is the transition from hospital to home if you cannot get the services the person needs at home when they are ready to transition? We are experiencing challenges with home health care ...
https://icd10monitor.medlearn.com/making-the-case-for-safe-transitions/
Last week saw the release of over 3,000 pages of new proposed regulations in the outpatient and physician fee schedule rules. No, I have not read it all. While there are many things that are very...
https://icd10monitor.medlearn.com/ruminating-on-reimbursement/
Chronic obstructive pulmonary disease, (COPD), is an overarching term for conditions which cause difficulty breathing, specifically from some type of impediment to air movement. The two main type...
https://icd10monitor.medlearn.com/2024-coding-clinic-2nd-quarter-copd-and-z79/
In the current political debate, we hit the issue of whether states can supersede federal rules on the requirement to provide certain emergency care. Specifically, what if states outlaw access ...
https://icd10monitor.medlearn.com/the-lifeline-of-emtala-ensuring-access-to-emergency-medical-care/
Today, I’d like to discuss the recently proposed policies by the Centers for Medicare & Medicaid Services (CMS) under the U.S. Department of Health and Human Services (HHS). These proposals are...
https://icd10monitor.medlearn.com/opps-proposed-rule-aims-to-improve-healthcare/
In a move to support individuals at high risk of suicide or overdose, the Centers for Medicare & Medicaid Services (CMS) is proposing changes in the payment structure and services to expand teleh...
What do we code for soft tissue ultrasound?
https://icd10monitor.medlearn.com/radiology-question-for-the-week-of-july-15-2024/
What time can be used for infusion stop if patient is in the clinic and has a negative reaction requiring inpatient admission?
https://icd10monitor.medlearn.com/general-question-for-the-week-of-july-15-2024/
When do we report 88367 vs. 88368?
https://icd10monitor.medlearn.com/laboratory-question-for-the-week-of-july-15-2024/
What determines medical necessity for billing pulse oximetry?
https://icd10monitor.medlearn.com/respiratory-question-for-the-week-of-july-15-2024/
How is IABP performed?
https://icd10monitor.medlearn.com/cardiology-question-for-the-week-of-july-15-2024/
Arch, carotid, and vertebral angiography are integral services included in head and neck interventional radiology coding. The reality is that codes encompassing head and neck IR coding are challe...
While CMS (the Centers for Medicare & Medicaid Services) usually releases new rules in the afternoon, on July 10 they chose to release the 2025 Outpatient Prospective Payment System (OPPS) Propos...
There seem to be variances, particularly regionally, regarding the use of the preadmission Hospital-Issued Notice of Non-coverage (HINN) and the Advance Beneficiary Notice of Non-coverage (ABN). ...
On June 28, the Centers for Medicare & Medicaid Services (CMS) announced a Proposed Rule titled Medicare Program: Mitigating the Impact of Significant, Anomalous, and Highly Suspect Billing Activ...
https://icd10monitor.medlearn.com/proposed-rule-on-shared-savings-calculations/
The ICD-10-CM codes and guidelines for the 2025 fiscal year (FY) have been released. The new codes will become effective on Oct. 1, 2024. The ICD-10-CM guidelines have minor updates, and include ...
https://icd10monitor.medlearn.com/are-you-ready-for-the-new-diagnosis-codes/
During the last week of June, the U.S. Supreme Court unraveled the 1984 decision Chevron v. Natural Resources Defense Council. Chevron has been one of the most-cited decisions in American law, be...
https://icd10monitor.medlearn.com/what-the-end-of-chevron-deference-may-mean-to-us/
What is an IABP, and why is it used?
https://icd10monitor.medlearn.com/cardiology-question-for-the-week-of-july-8-2024/
Can a subcutaneous injection of insulin administered to a patient be billed?
https://icd10monitor.medlearn.com/general-question-for-the-week-of-july-8-2024/
If left and right ultrasound exams for pleural effusions is performed, is it appropriate to report two units of code 76604? The code description states “includes mediastinum,” does that make ...
https://icd10monitor.medlearn.com/radiology-question-for-the-week-of-july-8-2024/
What code should be used for brushings or protected brushings during a bronchoscopy, and what important considerations should be taken into account when coding for inpatient versus outpatient pro...
https://icd10monitor.medlearn.com/respiratory-question-for-the-week-of-july-8-2024/
Last week I discussed the new-to-me terminology of “the patient-directed discharge.” Well, this week my new term is “administrative harm,” which was highlighted in an article in the Journ...
Recently, the U.S. Department of Justice (DOJ) issued a press release announcing a massive nationwide healthcare fraud bust, creating the types of headlines designed to strike fear in the hearts ...
Does a “willful” act under the federal Anti-Kickback Statute require a defendant to know that their conduct violates the law? That’s the question a whistleblower is asking the U.S. Supreme ...
https://icd10monitor.medlearn.com/knowledge-of-wrongdoing-at-heart-of-whistleblowers-long-road/
While healthcare cyberattacks have dominated the news lately, healthcare fraud has quietly emerged as an equally concerning issue. You may remember last year’s Operation Nightingale, whereby al...
https://icd10monitor.medlearn.com/federal-efforts-to-combat-healthcare-fraud-growing-in-scope/
The Quarterly Update for Clinical Laboratory Fee Schedule (CLFS) and Laboratory Services Subject to Reasonable Charge Payment contains a new series of PLA codes that are effective July 1, 2024. T...
https://icd10monitor.medlearn.com/2024-july-pla-codes-arrive/
Annual funding for entities driving Marketplace enrollment has increased tenfold since hitting pre-pandemic lows. An unprecedented number of individuals are now enrolled in Patient Protection and...
The American College of Physician Advisors’ CDI Committee (disclosure: I am Chair) has published materials on numerous CDI topics. Each set of materials consists of a document detailing the poi...
https://icd10monitor.medlearn.com/what-is-chronic-atrial-fibrillation-anyway/
On June 27, the Centers for Medicare & Medicaid Services (CMS) issued a proposed rule to update payment rates and policies for renal dialysis services for Medicare beneficiaries. The updates, eff...
As we begin the second half of the year, it is a convenient time to make plans and take stock of our coding operations. There will be much to do when the Inpatient Prospective Payment System (IPP...
https://icd10monitor.medlearn.com/ipps-planning-for-the-second-half-of-2024/
An unprecedented number of individuals are now enrolled in Patient Protection and Affordable Care Act (PPACA) Marketplace health insurance plans – and federal officials this week signaled that ...
When coding bronchoscopy procedures, why is it recommended that all code assignments be reviewed by a coding professional from the Health Information Management (HIM) department?
https://icd10monitor.medlearn.com/respiratory-question-for-the-week-of-july-1-2024/
If an IV antibiotic was administered but the MAR only contains the time the infusion started, can we charge for an IV push?
https://icd10monitor.medlearn.com/general-question-for-the-week-of-july-1-2024/
Which code should be used for selective inferior phrenic artery (IPA) arteriography when imaging the inferior phrenic arterial blood supply to the diaphragm, and which codes should be used for im...
https://icd10monitor.medlearn.com/cardiology-question-for-the-week-of-july-1-2024/
Which codes are used to report cytology of fluids, washings, or brushings, and what does code 88104 specifically report?
https://icd10monitor.medlearn.com/laboratory-question-for-the-week-of-july-1-2024/
Understanding how to accurately code and bill for medications and radiopharmaceuticals can be a complex process, especially with ongoing changes in Medicare policies. The JZ modifier, in particul...
EDITOR’S NOTE: Research input for this report was provided by Kate Choi, a junior at Brown University and a current government affairs intern at Zelis. Many of you may be familiar with the week...
A recent federal court decision coming out of New Jersey demonstrates the viability of an unusual kind of whistleblower: a privately defrauded party. The most common prototype of a whistleblower ...
Today I have a topic that is quite practical and applicable to the everyday work of readers. Many have discussed the power of our words. The wrong word or phrase can negatively influence the way ...
Four months after a significant cyberattack forced its systems offline, a UnitedHealth subsidiary, Change Healthcare, has disclosed a major data breach. In a recent notification, Change Healthcar...
An educational webinar on the process is being hosted next month. Federal health officials have announced the release of the Notice of Funding Opportunity (NOFO) application period for the newly ...
https://icd10monitor.medlearn.com/cms-releases-nofo-application-for-ibh-model/
Today I want to focus on the critical role of ICD-10 coding in the field of mental health and behavioral disorders. Accurate coding in this area is essential, not only for ensuring proper reimbur...
https://icd10monitor.medlearn.com/icd-10-coding-for-mental-health-and-behavioral-disorders/
All hospitals are struggling to some degree, with increasing payer denials and ongoing post-payment chart reviews resulting in a time-consuming process. According to a recent Premier survey of 51...
https://icd10monitor.medlearn.com/clinical-documentation-integrity-programs-in-the-spotlight/
The Centers for Medicare & Medicaid Services (CMS) has announced that payments under the Accelerated and Advance Payment (AAP) Program for the Change Healthcare/Optum Payment Disruption (CHOPD) w...
When you perform AHG technique, do you report all three of the codes, or just 86922?
https://icd10monitor.medlearn.com/laboratory-question-for-the-week-of-june-24-2024/
When should code 75774 be submitted, and when should it not be used, in the context of additional selective catheterizations after a basic study?
https://icd10monitor.medlearn.com/cardiology-question-for-the-week-of-june-24-2024/
What time can be used for infusion stop if the patient is in the clinic and has a negative reaction requiring inpatient admission?
https://icd10monitor.medlearn.com/general-question-for-the-week-of-june-24-2024/
An “ultrasound abdomen complete” (76700) is ordered with the indication of “Abdominal pain, evaluate for Umbilical Hernia.” The hernia images are not included in our protocol for abdomen ...
https://icd10monitor.medlearn.com/radiology-question-for-the-week-of-june-24-2024/
For inhalation treatments, what defines an episode of care?
https://icd10monitor.medlearn.com/respiratory-question-for-the-week-of-june-24-2024/
Sticking with the crowd often feels safe. But simply doing what everyone else is doing is not a substitute for analysis. I’m going to give you a peek inside my brain today. It may be a bit sc...
https://icd10monitor.medlearn.com/unconventional-wisdom-regarding-compliance-issues/
Artificial intelligence (AI) has become a fixture in healthcare revenue cycle management (RCM), an area where finance leaders are desperate for ways to relieve understaffed departments struggling...
https://icd10monitor.medlearn.com/effective-ai-in-healthcare-rcm-requires-a-human-touch/
If I were to ask you what affects healthcare spending, I’d likely get about as many answers as we have readers. Some might say advancing technology, a workforce shortage, prescription drug pric...
It has nearly been six months since 42 CFR 422.101(b)(2) within the Code of Federal Regulations was officially set into motion on Jan. 1, obligating Medicare Advantage (MA) plans to follow the Me...
Average annual growth in national health spending over the next decade is projected to be 5.6 percent, outpacing projected overall GDP. The developed nation that spends far more on healthcare per...
https://icd10monitor.medlearn.com/cms-releases-health-expenditure-projections-for-next-decade/
One thing I was never taught in my master’s in social work (MSW) program was the hospital requirement to complete a PASRR screening for every patient discharging to a skilled nursing facility (...
The new ICD-10-PCS codes for the 2025 fiscal year (FY) were posted on the Centers for Medicare & Medicaid Services website on June 6. The Version Summary reflects 371 new codes and 61 deleted cod...
https://icd10monitor.medlearn.com/new-icd-10-pcs-codes-are-here/
In the old days, you walked into a patient’s room, visually surveyed them, and exclaimed, “(Spicy expletive deleted!) This patient is septic!” and then you rushed out to start aggressive tr...
The Centers for Medicare & Medicaid Services (CMS) has released the July 2024 Outpatient Prospective Payment System (OPPS) update. The MLN Matters number is MM13632, and the Change Request Number...
https://icd10monitor.medlearn.com/july-opps-update-features-many-code-changes/
We received a patient from the ER who presented with severe pelvic pain. The HCG indicated pregnancy, but there was no intrauterine pregnancy so an ectopic is suspected. What is the correct CPT®...
https://icd10monitor.medlearn.com/radiology-question-for-the-week-of-june-17-2024/
What are the documentation requirements to bill for hydration?
https://icd10monitor.medlearn.com/general-question-for-the-week-of-june-17-2024/
What is the primary use of Code 36160, and why is translumbar access often required for this procedure?
https://icd10monitor.medlearn.com/cardiology-question-for-the-week-of-june-17-2024/
When interpreting a bone marrow biopsy, which code should be reported, and what additional code should be used if a cell block is prepared from the aspirated material and processed in the histolo...
https://icd10monitor.medlearn.com/laboratory-question-for-the-week-of-june-17-2024/
Is a face-to-face clinical evaluation required for a sleep study?
https://icd10monitor.medlearn.com/respiratory-question-for-the-week-of-june-17-2024/
Today is Sunday, June 16: Father’s Day 2024. Retailers across America had been marking the occasion with huge discounts on merchandise since their algorithms have alerted them to a possible ali...
EDITOR’S NOTE: In an earlier version of this article, which has since been corrected, two inaccuracies were noted. TEFCA was introduced by the U.S. Department of Health and Human Services Offic...
The U.S. Department of Health and Human Services (HHS), in collaboration with the Centers for Medicare & Medicaid Services (CMS) and the Substance Abuse and Mental Health Services Administration ...
https://icd10monitor.medlearn.com/ten-more-states-join-the-ccbhc-medicaid-demonstration-program/
Let’s start with a recent court case. SCAN health plan, a Medicare Advantage (MA) plan, recently sued Medicare because their star rating dropped from 4.5 to 3.5. They claimed that Medicare’s ...
We all know that Medicare and Medicaid reimbursements rates are awful. We also know that the states’ audit processes of healthcare providers causes damages to all such providers nationwide. Thr...
https://icd10monitor.medlearn.com/in-hot-pursuit-retro-reimbursement-rate-relief/
I have been preparing for the three August webinars on the Inpatient Prospective Payment System (IPPS) for the 2025 fiscal year (FY). The final rule is scheduled to be released before or on Aug. ...
https://icd10monitor.medlearn.com/best-advice-begin-now-to-prepare-for-2025/
A total of 10 states are being added to the demonstration program. A groundbreaking pilot program meant to combat the nation’s mental health and substance use crisis was expanded dramatically l...
https://icd10monitor.medlearn.com/hhs-drastically-expands-mental-health-substance-use-pilot-program/
Today, I want to explore a topic that’s not only timely, but also transformative for our field: the role of artificial intelligence (AI) in enhancing clinical documentation integrity (CDI). Reg...
What are the billing requirements for pulmonary rehabilitation (PR) codes 94625 and 94626?
https://icd10monitor.medlearn.com/respiratory-question-for-the-week-of-june-10-2024/
When applying an "antibody cocktail" which contains two or more separately interpretable antibodies, providers should refer to the NCCI policy narrative to determine billable units of service. Ac...
https://icd10monitor.medlearn.com/laboratory-question-for-the-week-of-june-10-2024/
Can an abdominal aortogram be reported if performed at the same session as selective renal angiography?
https://icd10monitor.medlearn.com/cardiology-question-for-the-week-of-june-10-2024/
How should reimbursement be handled when a SPECT code is reported with a whole body code?
https://icd10monitor.medlearn.com/radiology-question-for-the-week-of-june-10-2024/
When a stop time has not been recorded for the infusion, can an IVP be coded?
https://icd10monitor.medlearn.com/general-question-for-the-week-of-june-10-2024/
Breaking Down Biliary Tract Coding The biliary tract plays a critical role in the digestive process by transporting bile from the liver to the gallbladder and then to the duodenum. However, when ...
https://icd10monitor.medlearn.com/top-tips-for-accurate-biliary-tract-procedure-coding/
Today I am going to do something a little different. I am going to write about outpatient care in a bed from the regulatory side, and then Tiffany Ferguson is going to address operationalizing it...
https://icd10monitor.medlearn.com/outpatient-in-a-bed-compliance-is-key/
Most U.S. Department of Justice (DOJ) investigations do not end up in court. Defendants who lose a civil case risk large fines and penalties, while those who lose criminal cases may face prison t...
https://icd10monitor.medlearn.com/oig-cases-present-cautionary-tales-of-compliance/
EDITOR’S NOTE: This is a fictional story that could become much too real. In the bustling corridors of General Hospital USA, the heart of the administrative operations pulsed with urgency. The ...
https://icd10monitor.medlearn.com/how-hipaa-violations-can-surprise-you/
As we discuss the Inpatient Prospective Payment System (IPPS) Proposed Rule for the 2025 fiscal year (FY), I want to call attention to the FY 2024 updates. There are almost five months remaining ...
https://icd10monitor.medlearn.com/have-you-left-money-on-the-table/
The implementation of outpatient in a bed (OPIB) classifications in hospital settings presents unique challenges, particularly regarding billing, patient care, and regulatory compliance. These ch...
https://icd10monitor.medlearn.com/navigating-the-complexities-of-outpatient-in-a-bed-opib/
Clinical validation (CV) denials are plaguing us lately. When I work on projects entailing medical record review, I must admit that it is not unusual for me to agree with the payer. However, if a...
The Centers for Medicare & Medicaid Services (CMS) has proposed an episodic payment model, the Transforming Episode Accountability Model (TEAM). This is one of CMS’s “innovation” models. If...
https://icd10monitor.medlearn.com/cms-proposes-payment-models-for-surgical-procedures/
Are inpatient respiratory therapy services included in room and board?
https://icd10monitor.medlearn.com/general-question-for-the-week-of-june-3-2024/