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 ...

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 ...

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 ...

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 ...

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 ...

In the introduction, we discussed the three (3) edit types that make up the National Correct Coding Initiative (“NCCI”). Probably the most familiar of those edits are the procedure to procedure (“PTP”) edits, which bundle two codes together.

Don’t be tempted to underestimate this edit type. A common misconception is if two codes are bundled, you can just add a modifier 59.

First, there are quite a few “unbundling” modifiers. Modifier 59 should be the modifier of last resort.

Other NCCI unbundling modifiers are the anatomical modifiers (E1-E4, FA, F1-F9, TA, T1-T9, LT, RT, LC, ...

One of the best resources we frequently recommend to providers is the National Correct Coding Initiative (“NCCI”) policy manual. It is like using a crystal ball to peer into the mind of CMS. The policy manual explains why CMS has edits that bundle two codes together, or why CMS limits how many units of a particular code you can bill. More importantly, the manual explains when it is appropriate to override these edits and how to do it correctly.

This manual serves as a toolkit for providers, coders, and billers alike.  We recommend dedicating specific time to ...

Healthcare Real Estate Transactions

Jackson Health Confirms $90 Million Expansion. Jackson Health System has selected Skanska USA as the contractor to complete a $90 million renovation and expansion project that would make Miami’s largest hospital system even bigger. The project includes the demolition of two buildings to make way for tripling the size of the system’s emergency department at Jackson Memorial Hospital. The entire expansion project cost is estimated to be $300 million upon completion. The project also entails the relocation and installation of underground utilities. The new emergency department, designed by global architecture firm HKS, will be ...

The Centers for Medicare and Medicaid Services (CMS) included some changes related to RHCs and FQHCs in the 2024 Final Rule.

• As referenced in our second article, CMS will now allow addiction, drug, or alcohol counselors who meet the requirements of MHCs to enroll with Medicare as MHCs for both RHCs and FQHCs.
• CMS has shown a commitment to rural communities by extending the definition of direct supervision to allow for virtual presence through December 31, 2024. In addition, the required level of supervision for behavioral health services will be furnished as “incident to” a physician or NPP’s ...

Effective January 1, 2024, the Centers for Medicare and Medicaid Services (“CMS”) established an active payment status for CPT codes 96202 and 96203 (caregiver behavior management/modification training services) and CPT codes 97550, 97551, and 97552 (caregiver training services under a therapy plan of care established by a PT, OT, SLP).

Before we delve into the specifics of the codes, let’s look at CMS’ definition of a caregiver:

“An adult family member or other individual who has a significant relationship with, and who provides a broad range of assistance to, an individual with a chronic or other ...