Pinnacle's Blog & Publications

  • Compliant Speaker Programs: How Life Sciences Companies Can Mitigate Risk

    Posted On: May 23, 2024

    Pharmaceutical, medical device, and biotechnology companies (collectively life sciences companies or “LSCs”) utilize outside ‘experts’ (“Healthcare Professionals” and “Key Opinion Leaders”, collectively “HCPs/KOLs”) to provide a wide variety of activities. HCPs/KOLs are often engaged by product marketing/sales groups known as “thought leader liaisons” or “TLLs”, and by medical affairs departments referred to as “medical science liaisons” or “MSLs”. These clinical experts are often critical to an LSC’s success. Some of the activities they perform include, speaking, product training, advisory board participation, strategic market planning, assistance with regulatory submissions, ensuring the effective utilization of products, and serving as scientific ...

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  • CMS Finalized the Payment Updates for 2025 Medicare Advantage Programs – What Now?

    Posted On: May 16, 2024

    On April 1, 2024, the Centers for Medicare and Medicaid Services (“CMS”) finalized their Calendar Year (CY) 2025 rates for Medicare Advantage (“MA”) and Part D prescription drug programs. With the conversion to version 28 from version 24, along with the statement that payments from the government to MA plans will “increase” by an average of 3.70% ($16 billion) over 2024 / 2025 years, what does this mean for value-based care in general?

    With the federal government expecting to pay between $500-$600 billion dollars in MA payments to private health plans in CY 2025, it appears that ...

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  • Revolutionizing Medicare with ACO Primary Care Flex Model: Enhancing Access and Equity

    Posted On: April 25, 2024

    Every primary care physician (PCP) in the United States should be integrated into an accountable care model. The primary objective of accountable care models is to provide all participating healthcare providers with the necessary incentives and resources to deliver top-notch, coordinated, team-based care that prioritizes health promotion. By doing so, it aims to minimize fragmentation and reduce costs for individuals and the healthcare system as a whole.

    The Center for Medicare and Medicaid Innovation (CMS Innovation Center or “Innovation Center”) is embarking on an ambitious new strategy aimed at achieving fair outcomes through the provision of high-quality, ...

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  • 2023 Evaluation and Management Guideline Changes

    Posted On: April 23, 2024
    2023 Evaluation and Management Guideline Changes
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  • Visit Complexity Add-On Code G2211 FAQs

    Posted On: April 23, 2024

    Recently, we have been getting questions about the new Healthcare Common Procedural Coding System (“HCPCS”) code G2211 (Visit complexity inherent to evaluation and management associated with medical care services that serve as the continuing focal point for all needed health care services and/or with medical care services that are part of ongoing care related to a patient’s single, serious condition or a complex condition).

    This code went into effect for The Centers for Medicare and Medicaid Services (“CMS”) on 1/1/2024.

    As you can see from the description of the code, there is a lot to unpack ...

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  • National Correct Coding Initiative (“NCCI”) Manual: Bonus Article – Billing Bilateral Procedures

    Posted On: April 17, 2024

    If you have questions about how to properly bill Medicare for bilateral procedures, the National Correct Coding Initiative (“NCCI”) policy manual has your answers. Starting on page 30 of chapter 1 of the 2024 NCCI manual, they give detailed instructions.

     

    Step one – Look your code up in the Medicare Physician Fee Schedule Database (“MPFSDB”). Don’t know where to find the MPFSDB? No worries, we have you covered. The most direct way is to go to the Centers for Medicare and Medicaid Services’ (“CMS”) website and use their Fee Schedule Tool which is included the references section below. Follow these steps ...

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  • National Correct Coding Initiative (“NCCI”) Manual: Part Three – Add-On Code Edits

    Posted On: April 3, 2024

    In this series of articles on the National Correct Coding Initiative (“NCCI”) Policy Manual, we have discussed procedure to procedure (“PTP”) edits and medically unlikely edits (“MUE”), but were you aware that NCCI also has add-on code (“AOC”) edits?

    Add-on codes are codes that should not be reported alone. They will always be billed as an “add on” to a primary code. The Current Procedural Terminology (“CPT”) manual will indicate add-on codes with a “+” sign.  They may also give a list of primary codes that the add-on code can be reported in addition to.

    Most ...

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  • AHEAD Model: The Latest Innovation in the Shift to Value-Based Care

    Posted On: March 28, 2024

    Introduction & Background

     

    Following the enactment of the Patient Protection and Affordable Care Act (PPACA) in March 2010, the healthcare industry has experienced a major shift in its reimbursement and payment structure. While the United States healthcare system had historically operated under a fee-for-service (FFS) model, the PPACA initiated a notable shift to value-based care (VBC). Under the traditional FFS model, providers are paid separately for each medical service. Because of this structure, the FFS model has been characterized as a ‘volume-based’ payment model, under which healthcare expenditures notably increased. Many argue that this outcome ...

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  • National Correct Coding Initiative (“NCCI”) Manual: Part Two – Medically Unlikely Edits

    Posted On: March 26, 2024

    In part one we discussed procedure to procedure (“PTP”) edits. In this article we will discuss Medically Unlikely Edits (“MUEs”).

     

    The Centers for Medicare and Medicaid Services (“CMS”) defines an MUE as “the maximum units of service reported for a HCPCS/CPT code on the vast majority of appropriately reported claims by the same provider/supplier for the same beneficiary on the same date of service.”

     

    There are two types of MUEs, Claim line MUEs and date of service MUEs. This may just sound like semantics, but it really matters.

     

    A claim line MUE is adjudicated based on the units billed on the line item ...

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  • March is Kidney Awareness Month!

    Posted On: March 21, 2024

    Introduction

    March is Kidney Awareness Month, and Pinnacle wants to share updates regarding the new conversion from v24 to v28.  What better way to celebrate than to brush up on how kidney and underlying kidney related diseases affect Risk Adjustment!? As we move forward over the next three-year implementation, it is important to understand how this new model will affect everything we know about Medicare Advantage and Risk Adjustment.

    Chronic kidney disease (“CKD”), also known as chronic kidney failure, is a condition in which kidney function gradually declines. In its early stages, symptoms may not be ...

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Jaden Silva

MHA

Analyst


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