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Tag Archives: level

First level appeal for Medicare

Posted on by
We have a patient with Jr after his name. (e.g. John Smith Jr).

Our billing system would not recognize eligiblity if it is entered as John Smith Jr. but it would read it if it’s typed as John SmithJr.

However, our claims for 2018 keep on being denied by Palmetto GBA (TN MAC) as invalid, and if we rebilled it, it denies as duplicate (even if we have zero payments due to denials).

We have tried every permutation available for the name trying to get it to go through the computer systems.

Is it appropriate the go online for the first level appeal?

Thanks!

Medical Billing and Coding Forum

2019 HCPCS Level II Changes Released

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2019 HCPCS Level II changes are comprehensive this year, and the code set includes several new modifiers as well as codes. The Centers for Medicare & Medicaid Services (CMS) released them November 6. HCPCS General Talley The 374 changes are broken down this way: 228  new codes and modifiers 49 discontinued codes and modifiers 95 changed […]

The post 2019 HCPCS Level II Changes Released appeared first on AAPC Knowledge Center.

AAPC Knowledge Center

Establishe pt: Level 4 History, Level 4 Exam, Level 3 MDM

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So many visits by our new provider in seeing established patients are level 4 History, level 4 Exam, and Level 3 MDM, so I have to address this. (borderline level 3/4)
I understand medical necessity is usually determined by the provider since coders lack the clinical piece. I also understand MDM carries the most weight over History and Exam sections. Also, medical necessity is the overarching theme for the visit, beginning with the chief complaint–reason for the visit– and HPI and going through the exam and MDM. I just want to present both sides if I decide to go to the practice manager about this (AAPC side and our new providers side). Our new provider has been coding and seeing patients for 6 years at another practice.
I know this new provider is NOT copy/pasting from one note to another from prior visits in our practice and she is NOT having staff fill in blanks on EMR or NOR using prepopulated sections. I have gone through several weeks of her notes and her HPI and ROS are different for each patient. The ROS relates directly to chief complaint in each section. The exam is based also on reason for visit. Each of the 3 sections are described in relation to the individual patient and their chronic and acute problems.
The new provider in question is seeing patients who were being treated by 2 other of our providers, who just retired. So every condition is new to this new provider/examiner so she spends more time with her patients (new to her, but established to the practice)
So if she is gathering extra info on each patient because she is unfamiliar with their case and needs background info to treat them, does this constitute medical necessity?
In other words, which level would be billed when: History is detailed (level 4), Exam is detailed (level 4) and patient has 2 or 3 diagnoses/symptoms and Rx are NOT given?
Any advice on how to approach this subject with new provider or practice manager is appreciated.. I work at home remotely, so my correspondence is usually via email. Thank you for any assistance you may have. I welcome any viewpoint.

Medical Billing and Coding Forum

Detailed History and Detailed Exam support level 4?

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We have a new provider. She always documents a detailed History and Detailed Exam.
Her view is since she is new she is gathering detailed info on all her patients to get to know them. She usually gives an exam with at least 6 elements since these patients are new to her.
Her Medical Decision Making often has 2 or 3 dx without RX.
I’m often finding low level medical decision making.
Would these office visits be scored as level 3 or 4?
Thank you

Medical Billing and Coding Forum

Adjacent Level Fusion – Cervical & Thoracic

Posted on by
HELP!
Needing to estimate charges for an adjacent level cervical fusion, C4-5, and at same time thoracic adjacent level T1-2.
I’m thinking baseline code set:
22600,
22614,
22840×2,
22853
20931
I’m thinking posterior approach due to thoracic. Validated NCCI edits, none.
Am I missing anything?
No medical record to review at this date.
Any help will be appreciated.
Valerie

Medical Billing and Coding Forum

Level 5 Office Visits

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I have a provider that is insisting he was instructed by the ASCO to code all chemotherapy patients a level 5. I find this hard to believe. (FYI…We are seeing the patients in the office setting and not the ones who are administering the chemo. We do write the chemo order. The patient is receiving it outpatient through the hospital). Everything in his note states the patient is stable and doing well. Has anyone else heard this? Many of these patients are seen every 1-2 weeks and I do not see how all these appointments could be a level 5. I have asked the provider for a link or copy of this information but have not received a reply back. Any information anyone has would be greatly appreciated. Thank you!

His actual reply is as follows:

All patients getting chemotherapy would be considered high complexity management. They would all be considered "Drug therapy requiring intensive monitoring for toxicity"

This was a subject that came up at ASCO recently and everyone was surprised about billing them at level 4.

Medical Billing and Coding Forum

Nature of Presenting Problem’s Relationship to E&M Level

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I’m looking for clarification regarding the correct definition of "the nature of the presenting problem" and how chronic conditions without current exacerbation relate to the level of evaluation and management service. I’ve seen providers coding level 5 follow-up office visits for patients with debilitating chronic conditions that are stable with no current complaints. These are conditions like cerebral palsy, cognitive and functional impairment, Ehlers-Danlos syndrome, cystic fibrosis, etc. The physician may document medication changes or recommend new therapy. My understanding is that, regardless of how chronically ill a patient is, if they are currently stable and at their personal baseline, even though that baseline may be a pretty severe impairment, it is not appropriate to code a level 5 for routine follow-up with adjustments to the treatment plan and/or medication management. I’ve had colleagues argue that the underlying condition itself can be severe enough to complicate medical decision making to the extent that high complexity is supported, even without a current exacerbation, but I am unable to find any guidelines that address this specifically. Both 99214 and 99215 state "usually, the presenting problem(s) are of moderate to high severity". Does "the nature of the presenting problem" refer to the patient’s overall or underlying physical condition, or is it specific to the signs/symptoms or concerns present at the time of the encounter only?

Thanks

Medical Billing and Coding Forum

Carolyn Delap, CPC-A Looking for Entry Level Medical Billing/Coding position

Posted on by
Hello,

My name is Carolyn and I am a newly certified CPC-A with a Bachelor of Science degree in Computer Information Science. My goal is to help improve companies’ financial health through employment as a dedicated and detailed-focused medical coder/biller.

My background includes electronic health records, medical billing and coding, Microsoft Office, ICD-10-CM, CPT-4, and HCPCS Level II modifiers. During my training at Tulsa Technology, I practiced entering and verifying patient demographics, scheduling/canceling appointments, verifying insurance, and generating referrals. In addition, I covered all aspects of revenue cycle management, including collections and denials. Due to this training, I have the knowledge to carry out the expected job responsibilities with ease. Furthermore, through recent life experiences as a caretaker, I demonstrated my skills in multitasking, scheduling, communication and cross training. As a result, I am passionate about helping people through my strong commitment to high-quality work, attention to detail, and time management skills. With this strong knowledge base and accomplishments, I have already obtained my CPC-A certification from AAPC and expect to earn my CPB certification in October.

I am excited about becoming part of the medical coding/billing field and look forward to providing positive financial benefits through my excellent customer service skills, my administrative abilities, my willingness to learn new information, and my adaptability to changing job demands. I am attaching my resume for review and can be contacted at [email protected].

Attached Files

Medical Billing and Coding Forum