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SGR AND ICD-10 Update

Late last night, the House Rules Committee authorized legislation to go to the floor of the House that would delay for one year, the SGR related cuts in physician fee schedule payments scheduled to take effect on April 1. Under this legislation, those cuts would be delayed until April 1, 2015.

In addition, the bill would make a number of other changes in the Medicare program, not least of which would be a one-year delay in the ICD-10 transition. Under this bill, the Secretary of HHS would be prohibited from mandating use of ICD-10 until October 1, 2015.

The bill would also “extend” a variety of expiring provisions previously extended by Congress.

The bill is scheduled for consideration by the House on Thursday, March 27th under “suspension” (i.e. House temporarily suspends normal rules). In order for the House to take up this bill under “suspension,” a two-thirds (2/3) majority must agree to consider this bill. It is not clear whether the House Leadership has the two-thirds (2/3) majority votes.

A bill brought before the House under “suspension” cannot be amended.

HBMA is closely monitoring this situation and will report any significant developments.
March 26th 2014 View Post
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Billing for group visits where multiple patients are seen for one problem can cause confusion.
Generally, if the visit meets the threshold to bill an E/M service, the appropriate E/M code can be used to report the encounter with no issues.
You may not be able to bill an E/M code if the group visits include non-physician professionals, such as nutritionists or behavioral health specialists.
Instead, if your carrier permits it, the non-physician professional must use the codes for medical nutrition therapy (CPT code 97804) or health and behavior intervention (CPT code 96153).
Since there’s no official guidance from the Centers for Medicare & Medicaid Services (CMS) about billing for group visits, contact payors before reporting these services so you’ll know their specific requirements.
Info: Family Practice Management, Nov/Dec 2013 issue.
Reprinted with permission from
Keep Up to Date on Primary Care Coding & Reimbursement
January 24th 2014 View Post
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Is your office ready for the hurdles of the Affordable Care Act? We are helping our clients prepare for the upcoming Demonstration Program for Dual Eligible Medicare-Medicaid patients. The new entities, "Integrated Care Organization's", are preparing to launch July 1. Contact us today to learn about these new fee-for-service revenue opportunities for your practice.
January 8th 2014 View Post
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Is your business strategy based on a 3-5 year plan? You may want to incorporate a longer vision of 20-25 years out and test your model on a very changed world environment.

Yesterday we took the opportunity to attend a workshop put on by the NewNorth Center at the College of Business @ University of Michigan Dearborn. Phylinx continues to look for ways to keep our valued clients on the cutting edge to maintain their viability.

Contact us today for more valuable strategies to keep your practice fighting fit.

NewNorth Center
Leveraging creative with analytical, NewNorth Center helps people develop untapped potential in themselves, their team, and their company.
November 20th 2013 View Post
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Providers may be called upon to act as “health coaches” to their patients, giving them advice and support to manage their chronic conditions on their own.
No specific CPT codes exist for providing this service. So when billing, use a code from the preventive medicine individual counseling code series (99401-99404).
If the counseling is given during a preventive service (billed with codes 99381-99397), it can’t be reported separately because it’s considered part of the encounter.
Select the ICD-9 code from the V65.4x series (other counseling, not elsewhere classified).
Info: Family Practice Management, September/October 2013 issue.
Reprinted with permission from
Keep Up to Date on Primary Care Coding & Reimbursement
November 5th 2013 View Post
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A common dilemma faced by many practices is billing for a preventive service and a problem-focused service during the same patient encounter.
When billing for treatment of an illness during a patient’s preventive exam, the patient’s issue should be significant enough to warrant separate treatment.
As always, the problem should be separately identifiable from the preventive service. And the documentation used to support the preventive service can’t be used to support the problem-focused service, too.
Modifier -25 should be appended to the E/M code to indicate the service was separate and medically necessary.
Note: If the patient’s illness is severe enough to warrant billing a high-level E/M code for the complexity and medical decision-making involved in treatment, it’s best to delay the preventive service.
Preventive services such as routine physicals are meant to establish a baseline for a general plan of care. Providers can’t get a proper reading on a patient’s general health if the person is very ill.
Reprinted with permission from
Keep Up to Date on Primary Care Coding & Reimbursement

October 2013 - CPR Archives - California Medical Association
The California Medical Association (CMA) is a professional organization representing the physicians of the state of California. CMA serves members in all modes of practice and specialties and is dedicated to serving our member physicians through a comprehensive program of legislative, legal, regulat...
October 30th 2013 View Post
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Although Medicare and some private payors don’t provide reimbursement for after-hours services, other payors may pay practices for these visits.
Use code 99050 (services provided in the office at time other than regularly scheduled office hours, or days when the office is closed) if your providers ever see patients outside of normal business hours.
If your practice is regularly open for business during evenings, weekends or holidays, report code 99051 (services provided in the office during regularly scheduled evening, weekend, or holiday office hours, in addition to basic service).
Both codes should be billed along with the appropriate code for the visit or service provided.
Tip: To convince private payors to reimburse for these services during contract negotiations, it may help to remind them how much money they’ll save in the long run.
Patients may end up going to the ER for these visits instead – which means they’d be out more money than they would if the patient came to your practice for treatment.
Reprinted with permission from
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How to Code, Negotiate After-Hours Reimbursement at Your Practice | Physicians Practice
Here's why you should seek — and more importantly, how to code — reimbursement for after-hours services at your medical practice.
October 25th 2013 View Post
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When you’re billing Medicare for the administration of a drug in your office, you can bill for both the amount of the drug that you used and the unused portion.
The drug must be supplied by the office—not by the patient.
To bill for the unused portion of a drug, enter a separate line item on your claim with the appropriate HCPCS code for the drug and the number of unused units.
Generally, coders must also include modifier JW (drug or biological amount discarded/not administered to any patient) to indicate that the drug wasn’t used on a patient.
Modifier JW shouldn’t be included if the amount of the drug that was administered is equal to or less than the billing unit.
Example: If a patient is given 7 mg of a drug that comes in units of 10 mg, a practice would bill for using 10 mg of the drug.
Documentation to support this billing must include the exact dosage of the drug that was administered, along with the exact amount discarded and the reason why it wasn’t administered.
Reprinted with permission from
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Waste Not, Want Not: Billing Unused Drug Supplies | AAPC News
Physicians sometimes must discard an unused portion of a drug. If the physician (rather than the patient and/or facility) supplies the drug, Medicare may allow
October 22nd 2013 View Post
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eRx Incentive Payments

On September 5, 2013, WPS Medicare began issuing the 2012 eRx incentive payments. The Electronic Remittance Advice (ERA) will carry the "LE" and RX12 indicators in the PLB-03-1 and PLB-03-2 segments and the Standard Paper Remittance (SPR) will carry the message "This is an eRx incentive payment."
September 23rd 2013 View Post
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CoventryCares of Michigan now is part of the Aetna Medicaid family of managed Medicaid care plans. There are no immediate changes. The move to Aetna does not change member or provider services, and the plan name remains the same.
You still can reach provider services at the same number, 866-314-3784 or online at:

Coventry Medicaid Michigan: For Providers
Read about how OmniCare helps new and current providers cultivate their practices by leveraging the trusted network solutions offered by Coventry.
September 18th 2013 View Post