Pinnacle's Blog & Publications

  • 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


    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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  • National Correct Coding Initiative (“NCCI”) Manual: Part One – Procedure to Procedure Edits

    Posted On: March 19, 2024

    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, ...

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  • National Correct Coding Initiative (“NCCI”) Manual: The Ultimate Medicare Billing Toolkit

    Posted On: March 14, 2024

    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 ...

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  • PHC 1st Quarter 2024 Real Estate Newsletter

    Posted On: March 5, 2024

    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 ...

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  • 2024 Final Rule Part Four: Rural Health Clinics (RHCs) and Federally Qualified Health Centers (FQHCs)

    Posted On: February 15, 2024

    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 ...
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  • 2024 Final Rule Part Three: Caregiver Training Services

    Posted On: February 8, 2024

    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 ...

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  • 2024 Final Rule Part Two: Behavioral Health Services

    Posted On: February 1, 2024

    The 2024 Medicare Physician Fee Schedule Final Rule revealed some great advancements in behavioral health services and how CMS will allow them to be billed.  We will highlight some of those changes in this article, but be sure to review the official final rule sourced below.


    Starting January 1, 2024, marriage and family therapists (MFTs) and mental health counselors (MHCs) are permitted to bill for services through Medicare.  Addiction counselors or drug and alcohol counselors who meet requirements can be designated an MHC and enroll in Medicare as MHCs as well.


    Medicare defines both MFT and MHC services as “services for the ...

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  • 2024 Final Rule Part One: Split (or Shared) Evaluation and Management (“E/M”) Visits

    Posted On: January 25, 2024

    According to the Centers for Medicare and Medicaid Services (“CMS”), Medicare Physician Fee Schedule Final Rule:


    “Split (or shared) E/M visits refer to visits provided in part by physicians and in part by other NPPs in hospitals and other institutional settings.  For CY 2024, we’re finalizing a revision to our definition of “substantive portion” of a split (or shared) visit to include the revisions to the CPT guidelines.  For Medicare billing purposes, the “substantive portion” means more than half of the total time spent by the physician and or non-physician practitioner performing the split (or shared) visit, or a substantive part ...

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  • 2024 Final Rule Summary of Changes

    Posted On: January 18, 2024

    The 2024 Medicare Physician Fee Schedule Final Rule is packed with changes that will impact physician’s revenue. In this article, we provide an overview of some of those changes. Look for more detailed articles regarding these topics in our upcoming 4-part series.

    • The Centers for Medicare and Medicaid Services (“CMS”) reduced the conversion factor (“CV”) by 3.4%.
      • 2023 CV factor was $33.89.
      • 2024 CV factor will be $32.74.
    • The American Medical Association (“AMA”) added new codes for caregiver training.
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