Most physicians are familiar with the MIPS quality models: These are the Physician Quality Reporting System (PQRS) measures that we’ve been reporting for years with the old Medicare value-based purchasing program. What we don’t know much about are the new cost efficiency models in MIPS, which are based solely on hospital and physician ICD-10-CM/CPT claims data rather than a clinical abstraction of our medical records.
Documentation and coding based on time requires knowledge about the general principles of E/M documentation, common sets of codes used to bill for E/M services, and E/M services providers.
OCR’s 2016 guidance on patient access opened up a debate in the industry and brought questions about fulfilling patient access requests to the foreground.
U.S. District Court Judge Rudolph Contreras will hold a hearing December 21 for a lawsuit aimed at halting the CMS payment reduction for hospital outpatient drugs acquired through the 340B program, a policy set to go into effect January 1.
In July, Utah pain doctor Jahan Imani, MD, and Intermountain Medical Management, P.C., entered into a nearly $400,000 settlement with the OIG to resolve allegations that Imani’s practice submitted false or fraudulent claims due to improper modifier use for payment by improperly using modifier -59 with HCPCS code G0431.
As federal agencies release new and complex regulations for acute and postacute care facilities, providers are faced with the daunting task of unraveling and complying with the latest changes while ensuring patients receive quality care.
Physicians may be angry at the increased documentation, coding, and billing workflow and compliance activities they must perform to be successful in new reimbursement models. However, to avoid accustations of fraud and upcoding, they must develop their own OIG-recommended compliance plan and be open to rigorous feedback and advice.
Currently, there are no national guidelines for how facilities should assign evaluation and management (E/M) levels in the emergency department (ED). Under Medicare’s ambulatory payment classification (APC) system, facilities create their own internal guidelines for determining the ED visit level, and each facility must follow its own system to demonstrate compliance.
The focus of FY 2018 code changes is specificity. Payers now expect codes to reflect the exact diagnosis and care given before claims will be reimbursed. Increased granularity in both clinical documentation and coding is critical for revenue cycle success in the year ahead.
