Pinnacle's Blog & Publications

  • CMS Proposes Expanded Coverage for Carotid Artery Stenting (“CAS”)

    Posted On: August 10, 2023

    Traditionally, carotid endarterectomy has been the primary method of treating high-grade asymptomatic and symptomatic carotid artery stenosis. However, a minimally invasive technique known as carotid artery stenting (“CAS”) has evolved over the years.  This technique offers reduced postoperative pain, reduced potential for postoperative wound complications, and shorter hospital stays.

    On July 13, 2023, The Centers for Medicare and Medicaid Services (CMS) released a draft decision memorandum regarding carotid artery stenting that would expand coverage of the procedure and remove certain requirements for CAS facilities and operators.

    The proposal is a result of a national coverage analysis ...

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  • Telehealth Changes After Public Health Emergency

    Posted On: August 8, 2023

    COVID-19 public health emergency (PHE) ended on May 11, 2023.

    Medicare’s coverage of telehealth for outpatient services will be extended through the end of 2024. Patients may continue to receive telehealth services no matter where they are in the United States and may receive services in their home rather than going to the health care facility.  Although private insurance often follows Medicare’s lead, they may decide to alter their telehealth coverage earlier.

     

    Permanent Medicare Changes

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  • Mental Health Changes V24 to V28

    Posted On: August 3, 2023

    While mental health awareness month occurred in May, we need not forget the upcoming changes to Medicare Advantage members in CY 2024 and beyond.

    On March 31, 2023, The Centers for Medicare and Medicaid Services (“CMS”) released the CY 2024 Advance Notice for Medicare Advantage and Part D.  This advance notice will change everything we know about Risk Adjustment and Hierarchical Condition Category (HCC) Coding.

    In the final notice, CMS deleted forty (40) ICD-10-CM diagnosis codes that currently map to an HCC in version 24 that will no longer map to a payable HCC in version ...

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  • 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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Carey Lowe-Curry

CPC

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