Pinnacle's Blog & Publications

  • Proposed Rule Summary of Topics and Interesting Points: Physician Fee Schedule 2024

    Posted On: August 3, 2023

    Pinnacle has reviewed the proposed rule changes for CY2024 related to the Medicare Physician Fee schedule.  CMS has also published a fifteen (15) fact-sheet summary.  The condensed overview below was constructed to provide an at-a-glance topic list of the proposed changes awaiting public comment before it is finalized.  We hope this is helpful to allow our colleagues to peruse the list and investigate further any details that may affect their practice.

    • Medicare Conversion factor: decreased from $33.89 (2023) to $32.75 (2024), representing an across the board decrease in reimbursement of 3.34%.
    • Supporting & expanding patient access and care ...
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  • Every PCP Should Be In a Shared Savings Contract: Where do we start?

    Posted On: August 1, 2023

    In a time where healthcare costs continue to rise, there is a diverse range of payment models in use, ranging from traditional fee-for-service to global capitated payment, to stunt the growth in costs. The Health Care Payment Learning & Action Network (HCP-LAN) has identified four main categories of payment (as shown in Table 1). The primary objective of promoting value-based payment is to shift as many providers and as much revenue as feasible into the third and fourth categories.

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  • Modifier 25: Is Your Documentation Up to Par?

    Posted On: June 26, 2023

    Modifier 25 Scenarios

    Is your documentation up to par to support Modifier 25? First, you should read The Center for Medicare and Medicaid Services (CMS) National Correct Coding Initiative (NCCI) chapter manual guidelines. Check out chapter 1 and chapter 11.

    The CPT Manual defines modifier 25 as a “Significant, Separately Identifiable Evaluation and Management Service by the Same Physician or Other Qualified Health Care Professional on the Same Day of the Procedure or Other Service.” Modifier 25 may be appended to an evaluation and management (E&M) CPT code to indicate that the ...

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  • Medicare’s Change to the Split/Shared Billing Rules: Implications for Physician Compensation Planning

    Posted On: June 21, 2023

    1.  What is a split/shared service?

    This term refers to evaluation and management services that are performed partly by a physician and partly by a non-physician practitioner (NPP) who is in the same practice group as the physician. NPPs performing split/shared services include nurse practitioners, physician assistants, certified nurse specialists and certified nurse midwives. Importantly, the term “split/shared service” refers to evaluation and management services that are performed in a hospital or facility setting, not a physician office setting.

    2. What is the split/shared services rule change that everyone is talking about?

    The rule change ...

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  • As CMS Focuses on Quality, there are Monumental Changes to Reimbursement for Quality on the Horizon!

    Posted On: June 14, 2023

    The Centers for Medicare and Medicaid Services (“CMS”) utilize risk adjustment factors to estimate the cost of Medicare Advantage (“MA”) beneficiaries and those associated costs of providing care.  Risk adjustment factor scores govern the amount paid by the health plan during the year for the beneficiary’s care.  The risk adjustment scores factor in demographic and specific life and health information such as the beneficiary’s:

    • Age
    • Biological Sex
    • Geographical location
    • Dual coverage eligibility
    • Acquired health status
    • The presence and active nature of multiple chronic conditions whose level of severity are much greater, and the estimated cost to treat the beneficiary are estimated at ...
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  • Non-Compete Contracting in Healthcare: Potential Impact on Physician Contracting and Alignment

    Posted On: May 3, 2023

    Introduction

    A covenant not to compete (a.k.a. a non-compete agreement) is a contract or clause in a contract specifying that an employee or contractor (often through a professional services agreement) must not enter into competition with their employer or client.  This agreement is for a specified period of time after the employment or service contract is over. The covenant not to compete may be in the context of other restrictive covenants, such as confidentiality covenants that prohibit the employee or contractor from revealing proprietary information or secrets to any other parties during or after their employment or ...

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  • Tele-Nephrology – The Future is Now

    Posted On: March 14, 2023

    In recent years, the healthcare industry has seen a surge in the use of telehealth services, and nephrology is no exception. Remote nephrology, or tele-nephrology, involves the use of telecommunication technologies to provide nephrology services to patients who are not physically present in the same location as their healthcare provider (e-visits).

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  • PHC 3rd Quarter 2022 Real Estate Newsletter

    Posted On: February 22, 2023
      

    The Pinnacle Real Estate Group consists of a combination of professionals who use their extensive experience in both valuation and transaction services within the healthcare real estate industry to guide clients through multiple types of arrangements in a time-efficient and cost-effective manner.

    This Newsletter covers recent activity and conditions specifically impacting the national healthcare real estate market and those who are learning how to succeed in it.  The Pinnacle Real Estate Group has compiled the following current market information from sources such as CoStar, CBRE, and HREI.

    Healthcare Real Estate Transactions

    $10.75 Million MOB acquired ...

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  • CMS Changes ACO Application Cycle! Are You Ready?

    Posted On: February 21, 2023

    The Centers for Medicare and Medicaid Services finalized changes to the 2023 ACO application cycle steps and timelines. After collectively submitting 50+ successful applications, Pinnacle is excited to continue interpreting the ever-changing ACO policy and execute future applications with the learned lessons and best practices gathered over the years. Here are some of the major highlights of the changes:

    • The Notice of Intent to Apply (NOIA) has been eliminated. Typically, in the past applicants had to submit an NOIA around the first week of June. CMS eliminated this step and moved up Phase 1 of the application. ...
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  • New ACO/VBC Changes Announced: What You Need to Know!

    Posted On: February 16, 2023

    Our healthcare industry is undergoing a major transformation, with a focus on shifting from a fee-for-service model to a value-based model that prioritizes quality and outcomes over volume and cost. CMS Administrator Chiquita Brooks-LaSure, stated “Through the CMS accountable care initiatives and working with our partners, we have made significant progress in addressing our greatest healthcare challenges.” Administration is looking to further the engagement and participation in various payment models by planning to release three to four new payment models, including more key stakeholders in healthcare. These models will be centered around advancing primary care, engaging specialists in ...

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Meet the Authors

Amy Crenshaw-Pritchett

CCS, CPC-I, CPMA, CDEO, CASCC, CANPC, CRC, CDEC, CMPM, C-AHI

Sr. Manager, HCC Coding/Audit & Education Services


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