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APCs Weekly Monitor
This HTML-based e-mail newsletter provides weekly tips and advice on the new ambulatory payment classifications regulations. Topics include the outpatient code editor (OCE), complex coding issues, beneficiary co-payment discounting, and cross-department APCs tracking.
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APCs Weekly Monitor
Issue 49, December 18, 2009
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Editor's Note
Because of the holiday season, this is the final issue of APCs Weekly Monitor for 2009. -
Q/A: Coding for Dermabond® wound repair
Q: We have a question about Dermabond wound repair. Should we code and charge only HCPCS code G0168... -
Tip: Know whether your facility may provide kidney disease education
CMS’ 2010 OPPS final rule addresses a new benefit, coverage of kidney disease education... -
Understand challenges, opportunities with PET coverage
CMS’ current national coverage determination (NCD) is fairly straightforward, specifying the... -
Trivia
Whose novels include Go Tell It On The Mountain?
Issue 48, December 11, 2009
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Q/A: Coding 'in and out' bladder catherizations
Q: Can we code bladder catheterizations when a urine specimen is obtained for an analysis and the... -
Tip: Use modifier -58 for planned return to the OR
Physicians sometimes decide to perform surgery in stages. These situations involve a planned return... -
OPPS final rule: CMS changes drug payment formula, physician supervision
CMS revised requirements for physician supervision and finalized a variety of drug reimbursement... -
Trivia
Which Canadian city's name means "muddy water"?
Issue 47, December 4, 2009
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Q/A: Billing for self-administered drugs
Q: Is billing all self-administered drug (SAD) charges as integral to a procedure using revenue... -
Tip: Use procedural modifiers to further describe services
Procedural modifiers can provide a wealth of information to further describe services provided... -
New E codes require detailed documentation
We’ve all read or seen news reports about horrific accidents that occur when people send text... -
Trivia
What was the first of H.J. Heinz'® "57 varieties"?
Issue 46, November 20, 2009
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Q/A: Billing telemetry daily monitoring
Q: Can our hospital code and bill telemetry daily monitoring in conjunction with a chest pain... -
Tip: CPT Chapter 11 codes take precedence in OB/GYN cases
When coding OB/GYN procedures, remember that ICD-9 codes 630–679 in Chapter 11 (Complications... -
Master modifiers to ensure accurate reimbursement
Proper modifier use is a critical part of coding, billing, and reimbursement. Currently, coders may... -
Trivia
How many flowers are in the design stamped on each side of an Oreo cookie?
Issue 45, November 13, 2009
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Q/A: Documenting lesion size
Q: A surgeon excises a lesion on a patient’s back, but fails to document its size or the... -
Tip: Don't overlook small-dollar savings
When considering ways to reduce revenue loss at your facility, don’t look just for big-dollar... -
Examine codes for complex OB/GYN procedures
Operative notes for OB/GYN procedures can be long and complex, and coders must know how to sift... -
Trivia
What type of jungle animal was Shere Khan in Rudyard Kipling’s The Jungle Book?
Issue 44, November 6, 2009
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Q/A: May we bill an E/M code for a wound care first visit
Q. Several of our facilities that include hospital-based outpatient wound care clinics have... -
Tip: Determine the number of specimens to code surgical pathology correctly
If you perform a level IV surgical pathology (88305) on more than one specimen from the same... -
Eliminate missed charges, errors to reduce lost revenue
As more services shift from the inpatient to the outpatient setting, coders are under more pressure... -
Trivia
What are Captain Hook's last words in Peter Pan?
Issue 43, October 30, 2009
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Q/A: Calcium gluconate administration: Infusion or hydration?
Q. A patient who has undergone a kidney transplant and has plasmapheresis intravenously receives IV... -
Tip: Develop protocols for enforcing direct supervision requirements
All diagnostic tests require some level of physician supervision. Staff members need to know the... -
I/OCE quarterly update: CMS addresses condition code 44, billing for radiopharmaceuticals and nuclear medicine
As part of Medicare Claims Processing Manual (MCPM) Transmittal 1803—the October 2009 update... -
Trivia
Which phobia do you suffer from if you have an intense fear of Halloween?
Issue 42, October 23, 2009
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Q/A: Proper coding for multiple wounds at different sites
Q: A patient with multiple wounds at different sites receives active wound management at one wound... -
Tip: Distinguish between therapeutic and diagnostic tests
Facilities need to have a clear understanding of when a procedure is diagnostic and when it is... -
Bill and charge for supplies correctly to reduce risk and lost revenue
Hospital departments may be losing revenue for supplies because they don’t understand how... -
Trivia
Where in California did the last Pony Express ride end?
Issue 41, October 16, 2009
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Q/A: Does physician documentation in written reports constitute an official order?
Q: We don’t have the usual written orders for several tests. However, physicians dictate or... -
Tip: Appropriately report units in excess of MUE
In FAQ 8736, CMS instructs hospitals how to report units in excess of the medically unlikely edits... -
Hospital outpatient departments need to know who is supervising
Hospital outpatient departments can’t simply rely on the rest of the hospital staff... -
Trivia
Which one of the following is not considered a bone of the cranium?
Issue 40, October 9, 2009
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Q/A: Billing for ED services that cross days
Q: Patient arrives in ED September 7 at 23:00. ED clinical staff initiate an IV push and hydration... -
Tip: Determine whether a colonoscopy is really a screening procedure
Coding a screening colonoscopy should be relatively straightforward. However, the interpretation of... -
Modifier -59: Reduce risk, receive correct reimbursement
Correctly reporting modifier -59 can challenge even the experienced coder, but doing so... -
Trivia
W.C.Sellar and R.J.Yeatman wrote a humorous version of the history of England. What is its title?
Issue 39, October 2, 2009
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Q/A: Infusions in multilumen catheters
Q: How should we assign CPT codes for an infusion of desferal at the same time as blood products... -
Tip: Meet physician supervision requirements for diagnostic services
How can your facility ensure compliance with the physician supervision requirements for diagnostic... -
Two years later, MUEs remain a puzzle
A patient arrives at the hospital with a major head injury. The physician orders an MRI to evaluate... -
Trivia
Who has won the most Oscars for Best Actress?
Issue 38, September 25, 2009
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Q/A: Billing code 92960 in the ED
Q: Is elective cardioversion code 92960 billable in the ED? For example, a patient presents in the... -
Tip: Understand medically unlikely edits
CMS created medically unlikely edits (MUEs) to ensure that providers don’t report excessive... -
Physician supervision requirements not limited to therapeutic services
Many facilities are familiar with the physician supervision requirements for therapeutic services... -
Trivia
According to Greek mythology, who are Clotho, Lachesis, and Atropos?
Issue 37, September 18, 2009
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Q/A: Billing for items used with DME
Q: We understand that we cannot charge for the use of equipment, but can we charge for the soft... -
Tip: Understand Q status indicators
Under the 2009 OPPS final rule, bundling is now subdivided into status indicators Q1, Q2, and Q3. -
Decode the language of physicians
The language of the practice of medicine doesn’t always mesh with the language of coding... -
Trivia
Who is the youngest man to win the Oscar for Best Actor?
Issue 36, September 11, 2009
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Trivia
Where are the ethmoid sinuses located? -
Q/A: Billing for open but unused supplies
Q: Can we bill for supplies or implants that we opened but did not use? If so, how do we report... -
Tip: Differentiate between packaged and bundled services
To distinguish between bundled and packaged services, remember that bundling applies to coding and... -
NCDs clarify how to identify and report never events
Even though never events should never happen, there are occasions when they do. Providers continue...
Issue 35, September 5, 2009
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Q/A: Reporting code 96372 for one dose administered via two injections
Q. A physician orders one dose of a medication to be administered intramuscularly (IM) or... -
Tip: Know the general definiation of 'immediately available' for physician supervision
In its 2010 OPPS proposed rule, CMS acknowledges never having specifically defined... -
Concepts review: Distinguishing between packaged and bundled services
Staff members still trying to understand the differences between packaged and bundled services now... -
Trivia
Which one of the following is an inherited disorder of connective tissue?
Issue 33, August 28, 2009
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Q/A: Is patient considered high risk after non-adenomatious polyp removal?
Q: Is a patient who underwent a colonoscopy and polyp removal three years ago considered high risk... -
Resubmit comments on OPPS proposed rule
CMS requests that everyone who submitted comments on the 2010 proposed Physician Fee Schedule or... -
Separately payable drugs: New calculation method proposed for 2010 doesn?t equal increased payment
Pharmacy stakeholders hoping for an increase in payment rates for separately payable drugs in the... -
Trivia
Who has received the most Oscars for Best Director?
Issue 32, August 21, 2009
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Q/A: Coding for incomplete stent placement
Q: How should we code the following scenario: A patient arrives at the catheterization laboratory... -
Tip: Comment on the 2010 OPPS proposed rule
What do you thinkof the 2010 OPPS proposed rule? You can submit comments to CMS until August 31. -
2010 OPPS proposed rule: CMS proposes more changes to physician supervision requirements
One of CMS’ proposed changes outpatient supervision could be a huge boon to hospitals and... -
Trivia
Which is the highest point in all of U.S. territory?
Issue 31, August 13, 2009
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Q/A: Limits on PET scans
Q: Is there a limit on how frequently patients may receive PET scans, such as 78815 (Tumor... -
Tip: Use these principles to develop E/M coding guidelines
No national guidelines for E/M leveling exist, so facilities must develop their own. -
OPPS 2010 proposed rule: Earliest release brings fewer substantial policy changes
The text portion of the 2010 OPPS proposed rule is shorter than previous years’ rules, and... -
Trivia
The fibers that conduct electrical impulses that allow the heart to contract in a coordinated...
Issue 30, August 7, 2009
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Q/A: Report modifier -59 for EKGs performed before or after cardiac catheterization
Q. An APC edit states that 93005 (electrocardiogram, routine EKG with at least 12 leads; tracing... -
Tip: Look for injuries sustained during military service
Coders need to be aware of a new set of E codes that detail injuries sustained by military... -
Ensure medical necessity to curb outpatient revenue loss
Albert Einstein once said, “Insanity is doing the same thing over and over again and... -
Trivia
Who is the Greek goddess of victory?
Issue 29, July 31, 2009
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Q/A: Physical and occupational therapy in the outpatient department
Q: What are the guidelines for physician supervision for physical therapy/occupational therapy and... -
Tip: Use new fifth digit to specify type of anti-depressant poisoning
The ICD-9-CM code changes for fiscal year 2010 will include the addition of a fifth digit to code... -
Three new modifiers added for outpatient 'never events'
CMS introduced three new modifiers for use with the occurrence of three ‘never events&rsquo... -
Trivia
Which one of the following is the northernmost city in all of U.S. territory?
Issue 28, July 17, 2009
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Q/A: Use of modifier -25
Q: We know we should append CPT modifier –25 to the visit level when one of our EDs or... -
Q/A: Facility guidelines for E/M levels
Q: I work in a hospital outpatient clinic setting. Has CMS issued a deadline for developing... -
Tip: Consider non-coding tasks when setting coder productivity goals
When setting productivity goals, don’t forget to include non-coding responsibilities when... -
Tip: Ensure medical necessity to curb outpatient revenue loss
Providers must ensure the medical necessity of procedures they perform. To reduce revenue loss... -
Uncover this helpful GEM to assist with ICD-10 transition
ICD-10 implementation is nearly three years away, but CMS is ramping up its educational resources... -
New ICD-9-CM codes increase specificity
U.S. outpatient facilities won’t begin using ICD-10 codes until 2013, but they get a preview... -
Trivia
Which model has appeared on the cover of the Sports Illustrated swimsuit edition most frequently? -
Trivia
What is the longest muscle in the human body?
Issue 27, July 10, 2009
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Q/A: Coding for blood glucose checks
Q: Which CPT code is appropriate for blood glucose monitoring with a device such as... -
Tip: Outpatient coders’ expertise a resource for inpatient line-item billing
Hospitals often consider bedside services as outpatient services in the inpatient setting... -
Carefully review CMS' national coverage analysis on PET scans
For years, it has been a challenge for healthcare facilities to determine whether Medicare will... -
Trivia
Who did People magazine name as its first Sexiest Man Alive?
Issue 26, July 3, 2009
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Q/A: Appropriate use of code 96376
Q: My question pertains to CPT code 96376 (therapeutic, prophylactic, or diagnostic injection... -
Tip: Carefully review CMS' national coverage anaylsis on PET scans
Until now hospitals had difficulty determining if and when Medicare would cover PET scans for... -
Set the bar with outpatient coding productivity standards
Establishing coding productivity standards is a necessary and challenging part of managing an... -
Trivia
Where is the Fountain of the Four Rivers located?
Issue 25, June 26, 2009
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Q/A: Hydration services continuing past midnight
Q: How should we report hydration services that run past midnight into the next calendar day along... -
Tip: Don't forget to monitor coding productivity standards
Establishing coding productivity standards is a necessary and challenging aspect of managing an... -
Inpatient ancillary services: Are your costs covered?
As the current economic climate continues to constrict cash flow for consumers and payers alike... -
Trivia
Which king created the Step Pyramid, the first great stone complex in Egypt?
Issue 24, June 19, 2009
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Q/A: Critical care coding
Q: My question pertains to critical care provided in an ER at a Level 1 Trauma Center. If a patient... -
Tip: Criteria for condition code 44
Condition code 44, “inpatient admission changed to outpatient,” allows hospitals to... -
Perspectives on chronic left ventricular heart failure
Selecting a code for a patient with heart failure was fairly straightforward; fewer codes existed... -
Trivia
What is another term for a bunion?
Issue 23, June 12, 2009
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Q/A: CPT code 97760 and L-codes
Q: Please clarify the overlap between CPT code 97760 and the L-code. Precisely, when and... -
Tip: Base code on patient’s initial symptoms for undetermined diagnosis
When a physician is unable to determine a diagnosis at the time of the visit, coders should rely on... -
Medicare: No coverage for virtual colonoscopy screening
CMS published “Proposed Decision Memo for Screening Computed Tomography Colonography (CTC... -
Trivia
The procedure to remove the posterior arch of a vertebra is called:
Issue 22, June 5, 2009
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Q/A: Proper assignment of code 99211
Q: Can we bill 99211 for nursing services provided in a clinic when no physician is present in the... -
Tip: Document medical necessity for sleep tests
In March, CMS issued a decision memo broadening coverage of sleep testing for obstructive sleep... -
Go electronic to improve compliant charge capture
With increased ED volume, a government push toward wired solutions, and the demands of more... -
Trivia
Who was the first person to serve as U.S. ambassador to the United Nations?
Issue 21, May 29, 2009
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Q/A: Physician supervision requirements for outpatient facility
Q: The nurse practitioner (NP) and physician assistant (PA) staff the off-campus clinic with... -
Tip: Avoid injection and infusion pitfalls
Infusions, injections, and vaccine administration continue to represent a compliance risk from... -
Strong documentation puts OSA coverage trouble to sleep
CMS’ March 3 decision memo that broadens coverage of sleep testing for obstructive sleep... -
Trivia
Where can you find Alexander Graham Bell’s large box telephone, a Stroh violin, Barbie...
Issue 20, May 22, 2009
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Q/A: Billing for DME
Q: What if your hospital doesn’t have a DME license? Do you still use only the L codes? -
Tip: Understand Q status indicator subcategories
The 2009 OPPS final rule further divided the Q status indicator into three subcategories, with... -
CMS releases April I/OCE update
CMS released its April quarterly update to the I/OCE March 13, effective April 6 (“April 2009... -
Trivia
The vestibule of the mouth includes:
Issue 19, May 15, 2009
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Q/A: Global payment structure and scheduled ED visits
Q: A patient is seen in the ED for laceration repair and then returns for suture or staple removal... -
Tip: Ensure consistent application of charges
Many facilities still lack written and tested policies and procedures to ensure consistent... -
Conform to the new CMS physician supervision requirements
Hospitals seeking further discussion about CMS’ clarification of physician supervision... -
Trivia
TURP is an abbreviation for:
Issue 18, May 1, 2009
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Q/A: Billing for CPT Code 86022
Normal 0 false false false... -
Q/A: Medically Unlikely Edits
Q. Why would we receive a Medicare edit for code 96361 (IV infusion hydration each additional hour... -
Conform to the new CMS physician supervision requirements
Normal 0 false false false... -
Tip: Use flow sheets for critical care
Critical care should have flow sheets similar to those used in the intensive care unit (ICU). -
Tip: Q Status Indicators
The Q status indicators are temporary. When the OCE receives a claim for processing, it will... -
Solve the twin problems of ED revenue loss and compliance risk
Although the 2009 OPPS final rule didn’t introduce any major changes, EDs still face a host... -
New white paper details E/M auditing
Normal 0 false false false... -
Trivia
The suffix “orrhaphy” means: -
Trivia
The suffix “orrhaphy” means: -
Trivia
Normal 0 false false false... -
Clarification
Normal 0 false false false...
Issue 17, April 24, 2009
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Q&A: Coding and billing prosthetics and orthotics
In a physical therapy department, would it be appropriate to also bill CPT code 97760 in... -
HIPAA survey
We want to hear from business associates about their need for HIPAA training. -
Injection and infusion white paper available
The HCPro Revenue Cycle Institute has released a white paper on injection and infusion coding and... -
Trivia
Spring trivia
Issue 16, April 17, 2009
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QA:Coding multiple initial infusions
How you report what appear to be multiple initial scenarios depends on the documentation in the... -
Tip of the week
Everyone knows that an immense amount of teamwork is necessary for a CDI program to truly be... -
Championing the compliance cause
Christina Benjamin, MA, RHIA, CCS, CCS-P, presents several compliance traps that coders should... -
Trivia
Trivia: Thomas Jefferson, gardener
Issue 15, April 10, 2009
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Quarterly OPPS update has important supply billing changes
Changes in the second quarter OPPS update mean that orthotics and prosthetics, usually with HCPCS... -
CMS announces new publication and FAQs for ICD-10 mappings
CMS announced on April 6 that a new Medicare Learning Network publication, General Equivalence... -
Countdown to ICD-10
Normal 0 false false false MicrosoftInternetExplorer4... -
Trivia
April trivia: Boston marathon
Issue 14, April 3, 2009
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CMS has reformulated payments for some bilateral procedures
An increase in the Medicare payment for bilateral procedures with a status indicator of T slipped... -
Clearly document when sepsis or SIRS is POA
Never assume that sepsis is present on admission (POA). Sepsis or severe sepsis may be present on... -
Red Flags Rules deadline is May 1
Medical identity theft is an ugly reality for healthcare organizations, patients, and payers. It's... -
Trivia
Baseball trivia
Issue 13, March 27, 2009
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Q/A. One injection code or two?
When to code multiple injections as one dose. -
Tip of the week
Recovery audit contractors (RAC) cannot randomly select or target a claim "solely because it... -
CMS reviews negative pressure wound therapy devices
CMS has partnered with the Agency for Healthcare Research and Quality (AHRQ) to commission a review... -
Trivia
Birthday trivia
Issue 12, March 20, 2009
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Don’t use modifier -59 for E/M codes
Don't use modifier -59 (distinct procedural service) for E/M codes. Choose other modifiers... -
Tip of the week
Effective January 1, 2009, the CCI edits for E/M, including critical care, apply to hospitals. CMS... -
Watch for changing physician supervision requirements
Watch for changing physician supervision requirements -
Trivia
Basketball trivia
Issue 11, March 13, 2009
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Q&A. Separate reporting of infusions before and after CPR
The NCCI manual instructions state that: Procedures routinely performed as part of a comprehensive... -
Hospitals to report ZIP codes of outpatient service locations
CMS requires providers to report the ZIP code for off-site outpatient facilities. Effective July 6... -
Joint Commission makes changes to maintain deeming authority
by Jean S. Clark, RHIA It seems as though we can never stay ahead of the curve with respect to... -
Trivia
More Friday the 13th trivia
Issue 10, March 6, 2009
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While patient education alone isn't an E/M service, the technical component can be
Education alone is not a separate E/M service. However, it is customary to establish facility E/M... -
APC panel spring meeting
When the Advisory Panel on Ambulatory Payment Classification Groups panel (APC panel) holds its... -
2009 OIG Work Plan highlights compliance concerns
The OIG's list of Medicaid items is larger than it has been in the past, which means providers need... -
Trivia
More March Trivia
Issue 9, February 27, 2009
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Avoid modifier -58 in the ED
It’s hard to think of a situation in which you would use modifier -58 in the ED -
APC Panel holds meeting
The Advisory Panel on Ambulatory Payment Classification Groups panel (APC panel) met in Baltimore... -
RAC outreach sessions
With RAC officially underway, hospitals and providers should begin fine-tuning their RAC... -
ICD-10 is effective October 1, 2013
On January 15, the Department of Health and Human Services (HHS) announced the final rule to... -
Trivia
March trivia
Issue 8, February 20, 2009
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Charging CPR and injections or infusions with critical care
Q. Two questions: First, during CPR services, can we charge CPT code 92950 in addition to... -
Medicare announces final coverage policy of bariatric surgery for diabetes
CMS announced February 12 a clarification of its policy for Medicare coverage of bariatric surgery... -
Cigna bulletin boosts physician documentation
A December 2008 bulletin from CMS carrier Cigna should add an extra impetus for reluctant... -
Trivia
Washington's birthday trivia
Issue 7, February 13, 2009
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Q&A: Mutually exclusive procedures, NCCI edits
When procedures edit for being mutually exclusive or for one procedure being included in the code... -
RACs are back on track
CMS announced February 6 the permanent RAC program is once again underway as the RAC bid protests... -
Control charge compression
Charge compression is a complex, long-standing problem. And although CMS is only now recognizing... -
Trivia
Friday the 13th trivia.
Issue 6, February 6, 2009
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Unlisted CPT codes
New CMS guidance describes the processes for using unlisted CPT codes. -
Tip: Make HIPAA training fun
Mandatory HIPAA training usually generates the same excitement as a trip to the dentist. Sure, you... -
Charge compression basics
Buried in the 2009 OPPS final rule’s 1,800-plus pages is an important discussion of a fiscal... -
Trivia
Groundhog Day trivia
Issue 5, January 30, 2009
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CPT codes change in CCI edits April 1
Q&A: Why drug administration CPT codes are not hitting CCI edits. -
Tip: Use newly-available medical identity theft resources
HHS and the Office of the National Coordinator for Health Information Technology held a one-day... -
CPT: The back of the book
The Category II and Category III sections of the 2009 CPT Manual have seen many changes for 2009. -
Trivia
Wintertime trivia
Issue 4, January 23, 2009
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Integral insulin administration
Injectable drugs integral to outpatient treatment paid under OPPS, even if they are considered to... -
New NCDs on error prevention
CMS has issued three uniform National Coverage Determinations (NCDs) to clarify never events. The... -
2009 CPT checkup
CPT coders face a lengthy list of changes for 2009. There are over 700 changes, according to the... -
Trivia
Presidential trivia for inauguration week
Issue 3, January 16, 2009
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Q&A: Is older guidance on facility E/M billing still valid?
Federal Register guidance dating to 2000 still applies to facility E/M billing during the... -
2009 full payment update
More than 99 percent of hospitals participating in the Hospital Quality Data Reporting Program will... -
EHR could reshape your department
It’s every HIM director’s dream—a relatively seamless EHR implementation that... -
Trivia
Astrology trivia
Issue 2, January 9, 2009
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Billing replacement devices
Billing for a replacement/new device (C895) provided to a facility at no cost after October 1, 2008... -
The CPT errata list
The AMA has updated its list of errata to the 2009 CPT Manual. -
2009 Joint Commission manual changes
Effective this month, The Joint Commission will roll out new accreditation manuals that you may not... -
Trivia
Poker trivia
Issue 1, January 2, 2009
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New HCPCS II code set
Review this list of new HCPCS Level II codes for 2009 and be sure to order your 2009 Level II HCPCS... -
RAC focus areas
The RAC demonstration project revealed several target areas. HIM directors should focus on these... -
500-plus CPT changes in 2009
CPT coders face a lengthy list of changes for 2009. According to the American Academy of... -
Trivia
TV Trivia