Keeping Up to Date with KLA

2021 - Finally An Update to CMS E&M Guidelines

January 11th, 2021

With many of us doing virtual visits and avoiding social gatherings because of COVID, you may have missed that CMS's final rule eliminates 99201 and changes prolonged visit codes allowing a shorter time before charging such codes. 

CMS's new Evaluation and Management Guide has not yet been published BUT the AMA has published good information on topic. 

This resource can be found at

Thank you AMA for making this available!

Tags: Prolonged Care, Evaluation and Management


Quality Payment Program Look-Up Tool For 2018 MIPS Eligibility and Predictive Qualifying APM Participant Data

June 14th, 2018

On June 14 the Centers for Medicare & Medicaid Services (CMS) updated its Quality Payment Program Look-Up Tool to allow providers to see their 2018 Merit-based Incentive Payment System (MIPS) eligibility and Alternative Payment Model (APM) Qualifying APM Participant (QP) data. the Quality Payment Program Participation Status Tool was previously called the MIPS Participation Status Tool.

Just enter your National Provider Identifier (NPI) in the tool to find out:

  • Whether you need to participate in MIPS in 2018
  • Your Predictive QP status

Note: The Predictive QP status is based on calculations from claims with dates of service between 1/1/17 and 8/31/17.  IMPORTANT:  If you used dates of service from 9/1/17 through 12/31/17, your Predictive QP status will NOT be correct.

CMS determined Predictive QP status using the following analysis:

  • Identified eligible providers participating in Advanced APMs using the APM Entity participation lists.
  • Identified attribution-eligible beneficiaries from Medicare Parts A and B administrative claims data and Medicare beneficiary enrollment information.
  • Identified beneficiaries attributed to Advanced APM Entities.
  • Calculated payment amount Threshold Scores.
  • Calculated patient count Threshold Scores.
  • Determined predictive QP or Partial QP status for an APM Entity group based on the payment amount or patient count.
  • CMS applied the more advantageous QP Status to the eligible providers participating in the APM Entity.

Providers Can Also Check 2018 MIPS check group elibility. 

To check your group’s 2018 QPP eligibility:

  • Log into the CMS Quality Payment Program website with your EIDM credentials
  • Browse to the Taxpayer Identification Number affiliated with your group
  • Access the details screen to view the eligibility status of every clinician based on their NPI

In response to requests from providers, CMS also now allows providers to download the list of all NPIs associated with his TIN. The file includes eligibility information for each NPI.

Questsion may be directed to the Quality Payment Program Service Center by:

  • Email: QPP [at] cms.hhs [dot] gov
  • Phone: 1-866-288-8292/TTY: 1-877-715-6222
Tags: Quality Payment, Alternative Payment Mode, MIPS


CMS Acts on Pharmacy "Gag" Clauses

May 10th, 2018

Sometimes CMS headlines surprise me.  Take for example this one from May 17:

CMS Sends Clear Message to Plans: Stop Hiding Information from Patients

Not only was the headline an attention getter, the article informed me of a practice that seems unethical even if not illegal in the past.

Prior to this letter, Part D insurance carriers could (and some did) enter into contractual agreements with pharmacies that included gag clauses.  These clauses contractually prohibited pharmacists from telling patients that they would pay less for filling a prescription if they paid cash instead of using their insurance. 

How could that be?  Many Part D plans have mandatory copays and deductibles that would be more than the cost of the drug. 

Per the news release, on May 17,  the "Centers for Medicare & Medicaid Services (CMS) sent a letter to companies that provide Medicare prescription drug coverage in Part D explaining that so-called 'gag clauses' are unacceptable, as part of the Administration-wide “American Patients First” initiative to lower prescription drug costs...Today we are taking a significant step towards bringing full transparency to all the back-end deals that are being made at the expense of patients.” 

A copy of the letter that was sent to all Part D Plan Sponsors can be accessed at:

To learn more about the President’s blueprint to lower prescription drug costs, please visit:

Tags: Part D, Prescription Drugs


Billing for Services Not Listed in CPT

April 18th, 2018

It happens to most providers.  They provide services that do not meet the exact definition of a CPT code.

When compiling each year’s Current Procedural Terminology (CPT), the American Medical Association recognizes this reality and provides multiple methods for reporting services that fall outside of any CPT code’s exact definition. 

The first tools a coder should review when reporting such services are modifiers.  Some modifiers that may assist include:

  • 22           Increased Procedural Services
  • 23           Unusual Anesthesia
  • 52           Reduced Services
  • 53           Discontinued Procedure

Next check if there is an add-on procedure or a category III code that covers the procedure.  (Category III codes are temporary codes that represent emergent or experimental services, technology, and procedures.) 

When a modifier alone does not adequately change the CPT descriptor language enough to accurately describe the service rendered, the AMA has included in each section of CPT an unlisted procedure code-- usually ending in 99 and at the end of the section--that should be used to identify unlisted procedures.  A full listing of unlisted procedure codes also appears in the “Surgery Guidelines” portion of CPT®, prior to the 10000-series codes

Unlisted code do NOT:

  • Include descriptor language that specifies the components of the service; nor
  • Have RVU values assigned since they are used for services outside the norm when work (effort or skill), practice and malpractice expense have not been established.

The following is general advice on reporting such services.  Always check with your carriers for any variations that may apply.  

As an example, several years ago one of our clients began implanting leadless pacemakers.  Although Medicare had agreed to pay for these experimental services, the device had not received FDA approval (nor had it been grandfathered), and thus did not have an associated code.  After using the unlisted code for several months, we received IN WRITING guidance from our local carrier to use a standard pacemaker CPT codes to report leadless pacemakers since the carrier was paying based on the value of the standard codes.  We were to include in the descriptor field “Leadless Pacemaker” to differentiate from a standard pacemaker.

 Thus, the Medicare carrier actually requested the use of a standard code for an unlisted procedure to simplify their processing of the claims. 

Absent specific written guidance from your carrier, the AMA’s CPT Assistant offers these instructions for using unlisted codes:

Unlisted codes do not describe a specific procedure or service, so when using these codes, it is necessary to submit supporting documentation (e.g., an operative report, office notes) when filing the claim. This report is included to identify the specific information regarding the procedure(s) identified by the unlisted code. Relevant information should include an adequate definition or description of the nature, extent, and need for the procedure or service, as well as the time, effort, and equipment necessary to provide the service. The information may also include:

1) The specific service performed (including any assistance necessary to carry-out the service)

2) Whether the procedure was performed independent from other services provided, or if it was performed at the same surgical site or through the same surgical opening

3) The number of times the service was provided, and

4) Any extenuating circumstances which may have complicated the service(s) or procedure.

To assist the carrier in pricing the procedure, KLA suggest that you include in your request for payment a comparison to a CPT code or codes that approximate the RVU value of your service with an explanation as to why your service requires the same RVU.

When performing two or more procedures that require the use of the same unlisted code, the unlisted code used should only be reported once to identify the services provided.

Carriers are divided as to whether these claims should be submitted electronically. 

An unlisted procedure code or NOC must have a concise description of the services rendered in Item 19 on the CMS-1500 claim form or electronic equivalent. If you use the word “unlisted procedure” in this field, your claim will likely be denied. 

If submitting electronically, be sure to include the operative report and/or office notes and the RVU computation explanation as an attachment to the claim.  Otherwise the claim will be considered unprocessable.  Most carriers do not afford unprocessable claims filing status so these claims cannot be appealed.  (This could be critical for carriers with short appeal windows.)

The Centers for Medicare and Medicaid (CMS) addresses unlisted procedures in transmittal 1657.


Billing for unlisted drugs is beyond the scope of this post.  However, the following J codes may be of help. 

  • J3490 - Unclassified drugs
  • J3590 - Unclassified biologics
  • J9999 - Not otherwise classified, anti-neoplastic drug

Please note that most carriers apply different policies to compounded medicine and most require preapproval for the use of such drugs.

Tags: Unlisted Services


Were You Unexpectedly Dinged By Uncle This Year?

April 21st, 2016

Rarely do I discuss taxes here.  As most of you know, I’m a CPA and do many, many doctors’ office and individual practitioner tax returns each year.

2016 was an especially hard year to be a tax preparer.  Almost all my clients owed significant money because they had not properly withheld for the tax increases of the past few years.  Taxes will be even higher in 2016, so plan now to avoid another surprise tax bill and underpayment penalty.

During the last few years higher income taxpayers are bearing more and more of the burden of the federal government.  For example, in 2013  the top one percent of taxpayers accounted for more income taxes paid than the bottom 90 percent combined.

Are you and your spouse in the top one percent?  If together you make more than $400,000, you are.

Even if you aren’t in the top percent, the AVERAGE American works until April 24 before the dollars they keep are his own…ie, the average American pays almost a third of their income into federal taxes.

What are some of the tax hikes you need to be aware of to properly plan during 2016:

1.     Professionals' are special.  Their businesses are taxed at 35 percent on the first dollar earned.  Their is NO GRADUATED brackets for their corporations.

The biggest things that physicians (or other individuals classified as professionals) must be aware of is the PROFESSIONAL SERVICE TAX.  The IRS taxes professional corporations at a higher rate than that of regular corporations.  Specifically, profits are taxed at 35 percent regardless of the amount. Corporations of nonprofessionals are taxed just 15 percent on the first $50,000 in profits.  Thus, unless you are clever with your tax planning, a professional could easily pay 20 percent more on the same income. 

So when your tax preparer tells you at year end to empty out your corporation of income, listen!

2.     If a company you invest in moves out of the country, you pay tax as if YOU sold the stock.

As more and more U.S. companies move operations to more tax friendly countries, U.S. taxpayers face tax consequences because of “tax inversions”.  The IRS considers such deals taxable events, treating them as if long-term shareholders sold their stock and booked gains — even if they opted to exchange their holdings for shares in the newly incorporated company. 

We saw some substantial taxation on unrealized gains because of Medtronic’s acquisition of Dublin-based Covidien and relocation of the company’s tax home to Ireland.  Although Medtronic reimbursed its senior management to offset the tax liability, the move cost other taxpayers up to 33% on the difference between what they paid for the stock and what it was worth at the date of the acquisition.  It’s not fun calling a retired taxpayer to tell him he owes almost $100,000 because a company he invested in moved even though he hadn’t sold any of the stock.

Moral here:  using a discount broker and making your own investment decisions could cost you big in tax dollars.

3.  If your family makes more than $250,000 a year, you pay a surtax on your savings.

In January 2013, the Affordable Care Act’s 3.8% surtax on investment income went into effect  This applies to joint returns of $250,000+ or single returns of $200,000+. 

Other investment income was also impacted as follows:

                                               Capital Gains                Dividends                 Other Investment Income

2012                                              15%                           15%                                    35%

2013+                                           23.8%                         43.4%                                 43.4%

4.  If your family makes more than $250,000 a year, your Medicare rate increases.

Also in 2013, an increase in Medicare or self-employment tax to joint returns of $250,000+ or single returns of $200,000+ went into effect. This impacted many of our clients when both spouses make less than $200,000 a year.  If you fall within this category, your Medicare withholding goes from 1.45% to 2.35%.  If you are self-employed, you will pay 3.8% instead of 2.9% in self-employment taxes.

5.     If your family pays more than $27,500 a year for health insurance, get ready to pay a 40% excise tax for your Cadillac plan.

Those with health insurance costing more than $10,200 for an individual or $27,500 for a family, have to pay a 40% percent excise tax for a “Cadillac” insurance plan.

6.    Everyone pays more because of inflation.

The tax brackets have been indexed for inflation as they are every year.  For 2016, this will mean you will pay approximately .4% more in tax.

7.    Even if you have no income, if you don't have health insurance or your health insurance doesn't qualify, you have to pay a "penalty" up to $2,085.

Tax penalties related to not having “qualifying” health insurance are going up again.  The penalty for not have the right kind of health insurance will go up again in 2016 to $695 per adult or 2.5% of your income.  The per person amount is limited to $2,085 for families without qualifying insurance.


Bottom line: tax planning is no longer an option.  The .4% and the .9% and the 2.5% seem like small amounts BUT when added together, the impact to your bottom line can be huge.  High income taxpayers need to work closely with both a competent financial planner and tax advisor throughout the year to avoid big surprises in 2017.

Tags: Taxes, Affordable Care Act,


A Small Investment In Audio Visual Equipment = Big $ Potential With TeleMedicine

January 19th, 2016

CMS loves technology and a provider who is an early adopter of technologies can pump up their bottom line!  Most providers were familiar with dollars available with meaningful use and the adoption of EHR.

Less well known and with the potential for even more dollars is TeleMedicine.

By making a small investment in audio visual equipment where you can observe and ask questions of a patient as another provider serves as your “hands”,  both you at the “distance site” and the other provider as the “originating site” can be reimbursed by Medicare.  Such a scenario would work well both for specialists and primary care providers providing services  remotely to rural areas.

An added benefit for providing  these service is, as the patient needs to travel to the “big city” for services, the distance provider will oftenbe the first choice to render additional services to the patient.

Per the Medicare Learning Network’s publication , many services will be paid to providers at both the originating and distant site when you “use an interactive audio and video telecommunications system that permits real-time communication between you, at the distant site, and the beneficiary, at the originating site.”  Real time interactive audio and video is NOT just using a smart phone and/or home computer.  This must be professional grade equipment that allows you to remotely participate in patient care.

To be eligible for Telehealth service, the Medicare beneficiary must be located in

  • A rural Health Professional Shortage Area (HPSA) located either outside of a Metropolitan Statistical Area (MSA) or in a rural census tract; or
  • A county outside of a MSA.


So what exactly does that mean?  You can cut through the verbiage and enter the address at to determine if your originating site is eligible. 

Originating sites (the sites where the patient is located) can include:

  • The offices of physicians or practitioners;
  • Hospitals;
  • Critical Access Hospitals (CAH);
  • Rural Health Clinics;
  • Federally Qualified Health Centers;
  • Hospital-based or CAH-based Renal Dialysis Centers (including satellites);
  • Skilled Nursing Facilities (SNF); and
  • Community Mental Health Centers (CMHC).

 An independent renal dialysis facility cannot be an eligible originating site but beginning in 2016, a patient's home may be.

 The distant site providers that may provide Telehealth services include

  • Physicians;
  • Nurse practitioners (NP);
  • Physician assistants (PA);
  • Nurse-midwives;
  • Clinical nurse specialists (CNS);
  • Certified registered nurse anesthetists;
  • Clinical psychologists (CP) and clinical social workers (CSW). CPs and CSWs cannot bill for psychiatric diagnostic interview examinations with medical services or medical evaluation and management services under Medicare. These practitioners may not bill or receive payment for Current Procedural Terminology (CPT) codes 90792, 90833, 90836, and 90838; and
  • Registered dietitians or nutrition professionals


Providers should submit claims for telehealth services using the appropriate CPT or HCPCS code for the professional service along with the telehealth modifier GT, “via interactive audio and video telecommunications systems” (for example, 99201 GT). Using the GT modifier with a covered telehealth procedure code, certifies that the beneficiary was present at an eligible originating site when you furnished the telehealth service. By coding and billing the GT modifier with a covered ESRD-related service telehealth code, you are certifying that you furnished one “hands on” visit per month to examine the vascular access site.

The originating facility should bill HCPCS code Q3014 to the MAC as a part B charge.  The provider may also bill services rendered at the originating site.

Codes listed in the Medlearn publication plus billing codes and national allowed amounts can be accessed here.  Of course, providers must be qualified to provide the services!

Several new codes are available for 2016:  ESRD home services 90963-90966 which allows of 240.05 through 549.60 and Inpatient Prolonged Service Codes 99356 and 99357 which adds 92.44 for the first hour of prolonged service to the underlying evaluation and management code.

According to the Centers for telehealth, thirty-nine states also offer some sort of reimbursement for telehealth services through Medicaid.

Many private insurors also offer telehealth payments.  But as with all things new in healthcare, it’s best to check the rules first!

Tags: Telehealth


Battle New Year's Cash Flow Crunch with Preventive Services

January 7th, 2016

One of KLA's goals this year is to help our providers have the best year ever!  As part of that, we hope to help you improve your bottom line.

Here's a tip:

Now is the perfect time of year to incorporate preventive services into your practice as they are covered by most insurance companies without a copayment or deductible.  Plus, many of these are the same services that will help boost your "value added modifier"  and lead to you being paid at the higher end vs. lower end of payment scales in the years to come.

The preventive services spreadsheet
includes both the CPT code that should be used and the required ICD-10 Code.  Selections must be used from this list in order for the services to be paid as preventive services.

Limitations as to who is covered and where the service must be rendered are listed under "Who is covered."  Services  such as tobacco counseling have no limitations as to where the services may be rendered. 

Other services require a specialist's knowledge.  Glaucoma Screening requires a optometrist or ophtalmologist.

Many services such as intensive behavioral therapy for obesity and depression screening must be done in a primary care setting. 

Please take a look to see what services can boost your bottom line during the coming months.

Of special interest for radiologists is Lung Cancer screening which does not include up to date information on the spreadsheet.

Medicare (and most private insurances) cover:

Lung cancer screening with Low Dose Computed Tomography (LDCT) once per year for patients who meet all of these conditions:

  • They're 55-77.
  • They're asymptomatic (they don’t have signs or symptoms of lung cancer).
  • They're either a current smoker or have quit smoking within the last 15 years.
  • They have a tobacco smoking history of at least 30 “pack years” (an average of one pack a day for 30 years).
  • They get a written order from their physician or qualified non-physician practitioner.

The decision memo may be found at:

Please note that non traditional Medicare programs and other capitated programs may include these services as part of their capitation agreements.  We have also seen some ACO contracts that retain some of these as ACO services.


KLA is actively employing social media to pass on coding and other practice management tips to our clients and friends.  If you participate in social media, you may wish to follow KLA at:


Linked in:

Google +:


Thank you!

Tags: Preventive Services, Cash Flow


How To Make This The Best Year Ever for Your Medical Practice

January 4th, 2016

There is an old saying:  “Penny Wise and Pound Foolish.” The saying pokes fun at the miser who clips coupons to save a few pennies while rats eat away at the currency horded beneath his bed.

The last few years providers have focused on qualifying for “meaningful use” and on being penalized a few percentage points because a litany of back breaking burdens weren’t satisfied (which cost significantly more than a few percent to implement).  Some of these same providers are the same ones who have seen their census decline and bottom lines shrink.

Maybe we have all been paying too much attention to the pennies we may loose by being slow to comply with government mandates; and ignoring the profitable pounds of our business...superior patient care.

Let’s take a look at some of the ways to protect your pounds and to make this your best year ever…both in  profitability and personal satisfaction:

Understand your greatest asset is a satisfied patientLet me count the ways including:

  • A satisfied patient refers other patients.
  • A satisfied patient comes back for additional services.
  • A patient, whose needs are met, requires less of your staff time for follow-up.
  • A satisfied patient complains less and is far less likely to sue.

Be sure your phone is answered!  How hard is it for someone to get an appointment at your office? 

Recently I’ve had the need to make doctors' appointments for loved ones.  Not wanting to take advantage of my personal relationship with some of the offices, I've tried normal channels.  In one case I left a message three days in a row without ever getting a phone call back! 

My name is known at that office.  How many current and future patients do you think that physician has lost because of how his phones are handled.  How many are YOU LOOSING because you've relegated your phone to voice mail?  Recruit a friend to help you get a realistic answer to this question.  If it’s “ broke,” FIX IT!

Remind your staff that patients pay their salary.  We are all in the service industry.  Ultimately the kind of service we provide dictates our success level.  Is your staff respectful to all your patients?  Do they make your patients feel as if they are the most important thing when interacting with them; or are they walking the patients down the hall while texting or joking with other staff members?

Communicate with your patient.  Don’t expect your patients to understand the nature of their problems through a patient portal!  What you do is complicated!  After all, only the brightest and best become MDs.  Take the time to explain health issues to your patients. There may even be some reimbursement dollars available for doing so.   

You may also communicate health information including new services via newsletters or social media.

Bill for what you do!  So many providers are leaving dollars on the table because of what they perceive as heavy documentation requirements.  STOP IT!  Get the scribing help you need to document and capture charges for everything you do. 

If you don’t have a good certified coder on staff, get one!  In the meantime pay for a good consultant to come in and review your charges. So many office managers consider themselves as knowledgeable coders but they code as if it were the year 2000!

We have seen more than one practice that didn’t know how to bill for materials used inside a shot; or that didn’t know that there were different shot procedures.

Other offices no longer bill consulting codes to any payors...many privates still pay consulting codes.  Others are unaware how or when to use prolonged services to capture the time involved with a new consult.

Start with a review of well patient services...areas frequently unbilled.  This link is for Medicare, but most services are required to be paid by the Affordable Care Act.

Also take a look at some of the new services that can be billed for in 2016.  Your professional society likely has supplied information.  If not, follow KLA.  We are always on the lookout for new opportunities for you and have already addressed some of 2016's new billing opportunites on our blog.

Verify insurance, referrals and obtain necessary precerts.  Not checking that your patient's  insurance is current and all necessary referrals and precerts in place, will cost your practice thousands a year.  If you do high dollar procedures, the cost could be hundreds per case.

Take the time to personally review your high dollar procedures.  Check their payment status after forty-five days.  If they haven’t been paid, can your billing person tell you why?  Again, FIX IT!

We had a client who kept a list of each of his procedures and checked it against the billing records monthly.  This was brilliant. Not only was the doctor able to check that everything he did was billed, he also had a list that couldn’t be altered with a stroke of the practice management software making the procedure disappear from past due lists.   ( Most practice management software either does not offer a true double entry audit trail or such a trail is turned off for the ease of the billing staff. )

Collect patient cost share.  This is not an easy task, but grows more important with each year.  With the Affordable Care Act we have seen deductibles and copays/coinsurance consistently rise.  Ensure your front desk attempts to collect any unpaid balance at the time of service.  If the patient can’t pay, offer a payment plan.  Do not write off balances absent a properly completed hardship waiver.

Consider asking the patient to sign a credit card authorization that allows you to bill any balance after receiving an explanation of benefit from the insurance company.  If the patient is worried about the amount, include a limit in the agreement.  (Be sure to check your state laws about the proper form for this.) 

If the patient won’t pay his bill (and doesn’t have a real hardship), discharge the patient.  There are plenty of patients who would like the type of care you are providing.  Why take up space, time and spend extra dollars billing a patient who doesn’t value you enough to pay your bill?  Statistics also show that these types of patients are also those most likely to sue. 

Add a new service.  As our population ages, perhaps training in anti-aging medicine could provide a new reveue stream.  This has the added advantage of NOT being covered by most insurance.  Thus, you don’t have to bill insurance.

Sending a staff member to training and offering diabetic nutritional counseling is another possibility.  Most insurances pay for one on one or group counseling.

Telehealth offers is full of potential for specialists.  With a connection where you can see and hear a patient examination from afar, you and a primary care physician can both bill for the service AND provide specialty care to an underserved population.

It's time to get excited about your practice again.  Ultimately, it’s all about taking good care of your patients!  Isn’t this why you went into medicine in the first place? 

Happy 2016!

Tags: Billing and Collections


Year End Tax Moves for the Small Business

December 30th, 2015

As 2015 draws to a close, it’s not too late to consider a few moves to help keep more dollars in your pocket when Uncle Sam comes calling.

  1. Our clients often tell us they’ve “emptied out their bank accounts.”  That’s a good place to start but an empty bank account is not the same as no income for your business.  Many items that can legitimately be paid through a business are not expenses for tax purposes.  The biggest two items we run across that don’t lower a business’s income are payments on the principle of loans and 50% of business meals and entertainment.  If you have either of those items, the amount you paid will show up as income on your tax return.  It’s a type of “phantom income.”
  2. Prepay next year’s routine expenses.  The IRS allows a cash basis taxpayer to deduct payments when made if they become due within the next twelve months.  Consider office and malpractice insurance, rent, membership dues and other regular monthly expenses.  Special rules apply to officers’ life and health insurance so they aren’t the best choices to prepay.
  3. Buy equipment that you need for your business.  On December 18 a permanent small business annual expensing limit of $500,000 was signed into law,  the Protecting Americans from Tax Hikes (PATH) Act of 2015.  The law allows a business to expense up to $500,000 of equipment purchases each year.  This was a major victory for small business!  It means that, in most cases, equipment purchased and placed in service can be written off in the year of purchase.  There are special rules for cars but there is a $25,000 limit available for vehicles weighing more than 6,000 pounds and used more than 50% in business.  You can finance the purchase and take the full deduction even if you are paying over several months.  Beware:  this does not apply to most leases.
  4. Use credit cards smartly.  Normally using credit cards is an expensive way to finance a business.  A bank line of credit or loan is preferred.  However, at the end of the year any expenses charged may be deducted when charged as opposed to when paid.  This allows a company with no available cash to pay some bills at year end.  Pay off the credit card as soon as possible the following year.  (And remember paying off credit card bills are not expenses except as to interest…see 1 above.)
  5.  If you don’t have a retirement plan, consider setting up a SEP before year end.  These may be funded up to the due date of your return allowing you to offset 2015 income.   This is only for yearend planning.  A full featured retirement plan with a bonded fiduciary is the better choice for a permanent retirement plan.  Setting up these types of plans, however, take time.  Check with us for a recommendation for a proper retirement plan.  Most banks and brokerage houses have prototype forms to establish a SEP. 
  6.  If your spouse or children have helped in the business, consider putting them on the payroll and paying for the services rendered during the year. 
  7. If all else fails, bonus yourself!

The goal is to make your business income as low as possible.

Tags: Income Tax


Yes, You Can Bill For Telephone Calls If…

December 15th, 2015

It’s a head scratcher to me!

For months I’ve been telling providers about CPT Code 99490:  Chronic care management services (CCM), at least 20 minutes of clinical staff time directed by a physician or other qualified health care professional, per calendar month…

According to CMS in MLN Matters # SE1516:

 “CPT 99490 describes activities that are not typically or ordinarily furnished face-to-face, such as telephone communication, review of medical records and test results, and consultation and exchange of health information with other providers.”

Or the very things providers have been asking how to get reimbursed for years!  The national non-facility Medicare allowed for this code is a whopping $43.12…for 20 minutes of clinical staff time!  

Yet few of the providers KLA works with are using the code.

When I ask, “why not?,”  providers indicate that the record keeping requirements are just too great to justify the $43.12 they will be paid for  20 minutes of their staff time. 


If my math is right, that is an hourly rate of $129.36 for staff services?  Yes, there may be some initial paper work, but the reimbursement seems well worth the time.  Most of the time, the services are ALREADY being rendered.  It’s just the documentation that isn’t being done.

The requirements to qualify for payment under 99490 according to CPT are:

  1. During a month, at least twenty minutes of clinical staff time must be used to address the medical and/or psychosocial needs of the patient; (Clinical staff is defined in CPT and is a person who works under the general supervision of a the billing provider and who is allowed by law, regulation and facility policy to perform or assist in the performance of a specified professional service; but who does not individually report that professional service. Clinical staff are medical assistants, licensed practical nurse, etc.)
  2. The patient must have at least two chronic conditions that are expected to last at least 12 months, or until the death of the patient;
  3. These chronic conditions must place the patient at significant risk of death, acute exacerbation/decompensation of functional decline; and
  4. The services must be rendered under a comprehensive electronic care plan established, implemented, revised, or monitored (which of course must be documented in the patient’s chart which can be accessed 24/7.

In addition, CMS requires:

  1. CCM services must be discussed with the patient during a comprehensive E/M visit, an annual wellness visit or an initial preventive physical exam;
  2. The patient must consent to receive CCM services.  The consent form does not have to be signed at the time of the comprehensive service; and does not have to be signed each month;
  3. The patient must have telephone access 24/7.  This can be provided by an appropriate contracted outside service.  Most providers already provide this with an on call service;
  4. There are also some additional documentation requirements that are detailed at in the MLN Chronic Care Management Fact sheet found at:

If your staff is just too busy to provide the service and appropriately document, MLN Matters also states you can contract with appropriate outside clinical staff to do the work:

A billing physician (or other appropriate practitioner) may arrange to have CCM services provided by clinical staff external to the practice (for example, in a case management company) if all of the “incident to” and other rules for billing CCM to the PFS are met. Because there is a regulatory prohibition against payment for non-emergency Medicare services furnished outside of the United States (42 CFR 411.9), CCM services cannot be billed if they are provided to patients or by individuals located outside of the United States.

Because care management is an integral part of the services, Medicare does not allow CCM to be billed during the same service period as home health care supervision (HCPCS G0181), hospice care supervision (HCPCS G0182) or certain ESRD services (CPT 90951-90970).  In some cases you CAN also bill transition care management (CPT 99495 and 99496) during the same month.  The TM service must be completed before you start the CCM service.

If a provider is a member of an accountable care organization, chronic care management services may be provided by the ACO and  thus cannot be billed by the provider.  Check with your ACO to be sure.

Practice management guru Don Self estimates a solo practitioner could increase the bottom line by about $5,000 a month by implementing Chronic Care Management Services.  A free webinar on CCM available at the top of his page at:

If you are not aware of a reputable CCM service in your area that can assist, Don also has recommendations on CCM services that can help you offer this valuable service to your patients.

In today’s climate of deteriorating reimbursements, CCM can help reverse the trend.

Tags: Chronic Care Management


Payment by Medicare for End of Life Planning Begins in 2016

December 9th, 2015

Beginning in 2016, Medicare will begin paying for Advance Care Planning codes also referred to as “End of Life Codes.” 

According to CPT, 99497 is:  Advance care planning including the explanation and discussion of advance directives such as standard forms (with completion of such forms, when performed), by the physician or other qualified health care professional; first 30 minutes.

99498 is:  Each additional 30 minutes (List separately in addition to code for primary procedure.

National average Medicare allowed for 99497 is $82; and for 99498 is $72 so these codes will boost your bottom line when implemented.

By definition, these codes do not have to be face to face with the patient.  They can be with a patient’s surrogate such as a spouse or child.  (Be careful of HIPAA laws here.  Most states do allow a provider to select a surrogate based on the totality of circumstances.  Check with you malpractice carrier if you are unfamiliar with your state’s rules.)

Although face to face with the patient is not required, face to face remains a component.  There is no payment for handling end of life planning via telephone or mail.  Theoretically, these services would be reimbursed via the chronic care management codes.

Services can be rendered in an office or a facility setting, although they pay a little less in a facility setting.

Diagnosing and treatment are not elements of this code.  These codes are about helping a patient make appropriate arrangement for end of life.

Important terms to understand when using this code include:

  • Advance Directive:   A document which enables a person to make provision for his health care decisions in case if in the future, he becomes unable to make those decisions.   CPT specifically includes Health Care Proxy, Durable Power of Attorney, Living Will and Medical Order for Life-sustaining Treatment as examples. 
  • Other qualified health care professional: An individual who is qualified by education, training, licensure or regulation, who performs a professional service within his scope of practice and independently reports that professional service.  Typically this is an individual with his own license and NPI.

According to the head note in the Advance Care Planning section of CPT, an Advance Directive does not need to be completed in order to use the code; but the specifics of the form must be discussed.

These codes can be billed with most other evaluation and management codes with a modifier.  Pay attention to your documentation when doing this.  As is the rule with all coding, the various services need to be clearly delineated.  Ensure that you document your time elements separately from the evaluation and management services performed on the same day.  No double dipping!

Since advance care planning is an element of the Welcome to Medicare, do not code Advance Care Planning codes on the same day as an initial Medicare wellness visit. 

CMS has not issued national coverage determinations for these codes and has asked local MACs and carriers to do so.

Check with your private insurance carrier and with Medicare Advantage Carriers to see if they will pay these codes.  Also, look at any ACO contract to see if this is something that is part of any agreement you may have with them which would be part of the cost savings aspects and not an a charge that you can bill because of that contract.

Tags: Advance Care Planning, CPT, End of Life, Accountable Care Organizations


Additional Payment for Staff Time Begins in 2016

December 3rd, 2015

CPT has long recognized the need for codes to reimburse providers for the prolonged care of a patient. 

Until 2016 though, there was no apparent way to receive additional reimbursement because of the time a staff member spent in extended patient care.

With CPT 2016, two new codes are introduced to make reimbursement for this care possible.  They are:

99415: Prolonged clinical staff service (the service beyond the typical service time) during an evaluation and management service in the office or outpatient setting, direct patient contact with physician supervision; first hour (List separately in addition to code for outpatient Evaluation and Management service) (Use 99415 in conjunction with 99201, 99202, 99203, 99204, 99205, 99211, 99212, 99213, 99214, 99215)  (Do not report 99415 in conjunction with 99354, 99355)


99416: each additional 30 minutes (List separately in addition to code for prolonged service) (Use 99416 in conjunction with 99415)

And YES, Medicare will pay for these codes (although not much).

Although payment will vary slightly by jurisdiction, Medicare will pay approximately $8.00 for the first hour and $.50 for each additional 30 minutes your staff is involved in caring for the patient beyond the evaluation and management service. 

You cannot charge this in addition to provider prolonged service codes.  Nor should you charge it if you can bill for another. more appropriate service during the time such as instructing the patient on using an inhaler.  Thus, in order to charge these codes:

  1. There must be an office based evaluation and management service,
  2. The staff must be involved in direct patient care beyond the provider provided evaluation and management service,
  3. The provider cannot also charge for prolonged services,
  4. The staff member must provide the service under the direction and supervision of the provider, and
  5. Another code does not better reflect the service provided.

So little you say?  Although the reimbursement is less than what you are likely paying the staff member per hours, something is better than nothing!

Tags: Staff Time, Prolonged Services


CMS Tattles! But You Can Review and Dispute. Here's How...

April 23rd, 2015

According to CMS, on June 30, 2015, will make more information about the financial interactions between drug and medical device makers and physicians and teaching hospitals available to the public on its Open Payments website.

"Open Payments is a national effort that promotes transparency by making information reported by applicable manufacturers available on the website annually. Before the data is made public, CMS provides physicians and teaching hospitals the opportunity to register and review information submitted about them by applicable manufacturers and group purchasing organizations; if they disagree with what has been reported, physicians and teaching may initiate data disputes."



  1. Register in CMS’ Enterprise Portal (Enterprise Identification Management system – EIDM) to receive your CMS User ID. Use the EIDM Registration Quick Reference Guide to help you through this process.
  2. Register in the Open Payments system using your CMS User ID to review your payment records. Refer to the Physician Registration Quick Reference Guide or Teaching Hospital Registration Quick Reference Guide for assistance.

For more information about the registration process, visit the physician and teaching hospital registration page on the Open Payments website.

For assistance with the registration process, please call theHelp Desk at 1-855-326-8366,Monday through Friday, from 7:30 a.m. to 6:30 p.m. (CT), excluding Federal holidays. Questions can also be submitted to the Help Desk via email, at openpayments [at] cms.hhs [dot] gov" target="_blank">

Tags: Open Payments, Transparency


Plump Up Your Bottom Line While Helping Patients Slim Down

February 20th, 2015

CMS recognizes that obesity is a major cause of health problems in the US; and will pay providers to help their patients combat it! 

When a patient has a BMI of 30 kg/m2 or higher a Medicare will reimburse  for up to 22 visits in a year: 

  • One visit per week for the first month
  • One visit every other week between months two and six.
  • And for those patients lose 6.6 pounds during the first six months, one visit per month for the next six months!

When providing services for obestiy counseling to Medicare patients, report one of the following G codes:

  • G0447 (Face-to-face behavioral counseling for obesity, 15 minutes)  (National reimbursement - $26.10)
  • G0473 (Face-to-face behavioral counseling for obesity, group [2-10], 30 minutes)  - One unit is reported for each person in the group! (National reimbursement - $12.51)

The 22 units per year includes both individual and group counseling.

In order to appropriately document care, the Medicare Compliance & Reimbursement Alert says to:

...Keep the “Five A” strategy in mind when completing your documentation to ensure that the following five factors are in your documentation:

1. Assess. Ask the patient about his behavioral health risk and any factors impacting his choice of behavior change goals and methods.

2. Advise. Offer clear and specific personalized behavior change advice, with information about personal health harms and benefits.

3. Agree. Work with the patient to choose treatment goals and methods that the patient will likely be willing to perform.

4. Assist. Help the patient achieve his goals via behavior change techniques like counseling so he can get the skills, confidence and support required to follow the plan, supplemented with adjunctive medical treatments when appropriate.

5. Arrange. Schedule follow-ups to continue to support the patient and adjust the treatment plan when necessary.

For more information on obesity counseling, check the Medicare Claims Processing Manual at and the MLN Matters article at

Tags: Preventive Care, Obesity Counseling


Ch..Ch..Ch..Changes: Bill Eliminates SGR, Most Quality Incentives and Introduces Payment for Performance

February 10th, 2014

There appears to be strong bipartisan support for a bill that repeals SGR and that

  • Provides for annual automatic payment updates of 0.5% for five years (2014 – 2018)
  • Discontinues automatic updates for five years, beginning in 2018
  • Consolidates the three existing Medicare quality programs into a single value-based incentive the Merit-based Incentive
  • Payment (MIP) Program
  • Provides for increased Medicare payments based upon score on a (MIP), beginning in 2018
  • Would resume annual automatic updates beginning in 2024. All providers would receive an update, but the amount of the automatic update would vary from .5% to 1%
  • Provides incentives, such as a 5% bonus to providers who receive a significant portion of their revenue from an APM, for providers to switch to alternative payment models (APMs)
  • Expands the availability of Medicare data to patients and certain qualified entities.

As predicted by experts that follow HHI trends, the legislation appears to be based on the Prometheus model.  The payment system will use four measures to determine a provider's "merit."  Although we do not yet know what weight each of the four measures will be afforded, IF the Prometheus model is followed, the goal will be to reward with higher payments providers that manage their patients in the most financially efficient way while maintaining the quality of care.

Reading the legislative history, Congress feels the incentives previously offered have not had the effects expected and instead of lowering the cost of healthcare, have driven it up.  Thus, the new payment methodology will be largely OUTCOMES based.

A section by section breakdown of the bill can be found here

To understand where the Prometheus model in healthcare delivery is leading our healthcare industry, visit:

In a sense, what is old will be new again.  The government will be less concerned about HOW a provider does his job, and more concerned about the effectiveness.

We have some changes coming!

Tags: SGR, MIP


New Medicare Dashboard Improves Medical Documentation For People with Multiple Conditions

April 11th, 2013

The Centers for Medicare & Medicaid Services (CMS) announced the launch of its Medicare Chronic Conditions Dashboard, a valuable tool for physicians, researchers and policymakers. In line with the Affordable Care Act's goals for prevention and management of multiple chronic conditions, the dashboard will track medical documentation such as where multiple conditions occur, what services are being provided and how much Medicare is spending on patients who suffer from more than one chronic illness. CMS say the new tool has two major positive implications. 

  1. Improve overall care. The dashboard will help researchers and physicians better understand how certain overlapping medical conditions are related to overall health. Identifying common conditions among multiple patients will lead to better preventative measures, improve health outcomes and offer a more patient-centered approach. Two-thirds of Medicare recipients have two or more chronic conditions. Improving their treatment will have a substantial effect on overall health. 
  2. Support new policies. Policies to decrease costs are necessary, but hard to implement. Cutting benefits or physician reimbursement is not a popular choice and jeopardizes the quality of care. Dashboard data provides the needed analytics to propose new policies to streamline treatment and preventative measures for people with multiple chronic conditions. How much of a difference could this make? In 2011, $276 million was spent on Medicare beneficiaries with two or more chronic illnesses, approximately 93 percent of total Medicare spending. New policies based on solid data will help reduce costs while providing improved care. 

Findings based on dashboard data will contribute to transforming Medicare into a value-based purchaser instead of a fee-for-service payer. The goal of this transformation is for Medicare to pay based on quality and efficiency of care instead of just the volume of services. As the dashboard develops, the CMS will no doubt announce further information about gathering the data.

For additional information please visit:

Tags: Chronic Condition Dashboard


Transitional Care Codes Offer Increased Reimbursement Opportunities

April 5th, 2013

If you have a hospital practice, you probably know about 2013's new Transitional Care Codes.  These codes are among the first to pay (in part) for telephone followups to patients.  Yes, a face to face is also required, but payment is more than payment for a routine evaluation and management code.


The increased payment is designed to reimburse providers who provide services to transition a patient from inpatent status in a hospital or skilled nursing facility into a non-skilled setting.  The reimbursement recognizes the non face-to-face aspects involved in such a transition.


The definitions of the codes are:


99496 - Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of high complexity during the service period Face-to-face visit, within 7 calendar days of discharge.  (National Medicare Fee:  231.36)


99495 - Transitional Care Management Services with the following required elements: Communication (direct contact, telephone, electronic) with the patient and/or caregiver within 2 business days of discharge Medical decision making of at least moderate complexity during the service period Face-to-face visit, within 14 calendar days of discharge.  (National Medicare Fee:  163.99)


The "complexity" is based on standard definitions of complexity.  Thus, at least moderate complexity decision making is required before one of the codes can be used.


The services should be reported by only one provider within 30 days of discharge.  Best practices dictate that the provider using the code be the one charged with followup care of the patient.  This will NOT ALWAYS be the primary care or admitting provider.  For example, if a patient was admitted with hip pain which was discovered to be malignant; the oncologist, not the admitting doctor would likely be primarily responsible for followup care


If followup is in a global surgery period, and the inpatient stay was related to the surgery, billing for transitional care would not be appropriate during the global surgery period.


If the patient does go back to the hospital, inpatient services may be billed again.  If the patient comes to the office for a non related evaluation and management during the transitional period, the evaluation and management may be billed.


The codes should be billed AFTER thirty days of care has been provided.


The American Academy of Family Physicians has published some good guidance and tools on these new codes.   You can find the article and associated tools at: The AAFP tool includes basic information on what should be documented when using the codes. 


Medicare has addressed the new codes with a Frequently Asked Questions article which may be found at: These codes appear to be a way of increasing reimbursement for followups after a hospital stay by up to $60.  Keep in mind that an evaluation and management and other services NOT associated with the hospital stay may be billed in addition to the Transitional Care codes.  If the purpose of the followup visit is strictly to see how a patient is doing after a hospital stay, an evaluation and management should NOT be billed. If, however, the evaluation and management is unrelated to the hospital stay, an evaluation and management code may also be billed.

For those interested in reading about the new codes in the Federal Registry, visit page 90 in the pdf at this link:  (The page number read 68979).  The discussion begins about halfway down the first column. 


Per Medicare CCI, a physician or other qualified health care professional who reports codes 99495, 99496 may not also report care plan oversight services (99339, 99340, 99374-99380), prolonged services without direct patient contact (99358, 99359), anticoagulant management (99363, 99364), medical team conferences (99366-99368), education and training (98960-98962, 99071, 99078), telephone services (98966-98968, 99441-99443), end stage renal disease services (90951-90970), online medical evaluation services (98969, 99444), preparation of special reports (99080), analysis of data (99090, 99091), complex chronic care coordination services (99487-99489), medication therapy management services (99605-99607), during the time period covered by the transitional care management services codes.


Tags: Transitional Care Codes


New Waived Tests

March 18th, 2013

Medicare has approved additional tests to be performed under a certificate of CLIA waiver.

The MedLearn article is available at:

Tags: Waived Tests


Correcting Medical Records

March 4th, 2013

Every doctor has experienced it: the moment when he or she is reviewing a case file, and realized they have omitted a key piece of information. Just as often, a patient returns to the office with the revelation that they were incorrect about a symptom, or past condition, or some other key information regarding their medical history. Now, what can you do? From the moment that pen touches paper, or fingers hit the keyboard, the document in front of you becomes a legal record.

Luckily, you can amend the record. There is a right way to do this and there is most definitely a wrong way. Do not, under any circumstances, obscure the original information. If you are still keeping paper records, strike through the wrong information with a single pen line, add in the correction or amendment with a new document or (if the information is minor) a signed and dated note in the margin.

The same principal applies to electronic records. Make sure that you indicate which information was original, and which is the addendum. Make sure you electronically date and sign the record changes.

In their guidelines, the CMS Manual System states:

Regardless of whether a documentation submission originates from a paper record or an electronic health record, documents submitted to MACs, CERT, Recovery Auditors, and ZPICs containing amendments, corrections or addenda must:

1. Clearly and permanently identify any amendment, correction or delayed entry as such, and
2. Clearly indicate the date and author of any amendment, correction or delayed entry, and
3. Not delete but instead clearly identify all original content.

Correcting medical records legally is not rocket science, but it does take finesse and know-how. KLA Healthcare Consultants can help you navigate the regulations.

Please contact us with any questions or comments you may have regarding correcting medical records legally.

Tags: Medical Records


Medicare Fraud Strike Force: Increasing Pressure For Recovery Efforts

February 7th, 2013

Since its development in 2007, the Medicare Fraud Strike Force has brought more than 1480 defendents to justice and uncovered over $4.8 billion in funds that were falsely billed to Medicare.  As impressive as these numbers are, Medicare compliance efforts are demanding an increase in the strike force's recovery efforts.  

Health care reform costs are projected to be very high, and there's a very real need to address the deficit that the country is facing.  There's never been a better time to begin to enforce a Medicare compliance task force, regardless of how big or small your medical setting is.  

CEO's are encouraged to put into place experienced compliance professionals that can oversee the Medicare billing procedures in hospitals and doctors offices.  However, for those individuals to be as effective as possible, their placement needs to be handled the right way.  There are a few things CEO's can do to empower compliance professionals that will enable them to find solutions to any issues they may find.

Establish Compliance Officer's Authority

This is probably the most important because without the power to manage a comprehensive compliance program, the Compliance Officer's role is undermined from the beginning.  Each Compliance Officer must be granted the power to make changes and to make them as quickly as possible.

Establish A Regular Reporting Schedule

CEO's should be meeting with Compliance Officers on a regular basis for the purpose of looking at compliance reports.  Regular reporting is the functioning element of any compliance program, and they shed light on issues that require immediate attention.  

Establish Routine Audits

In order to keep the program on track, audits should be performed by the Compliance Officer and the CEO on a regular basis.  This will prove whether or not the proper measures to fix Medicare compliance issues are being addressed in a timely manner.  When audits are done properly, they will also reveal anyone who might be standing in the way of full Medicare compliance.

At KLA Healthcare Consultants we take your medical billing seriously.  We are proud to be a part of The Healthcare Billing and Management Association, which holds high standards for their members with regard to Medicare compliance.  We're here to serve you in your billing needs and assist with any of your Medicare compliance questions.  For more information, contact us today.

Tags: Medicare Compliance


CMS Expands Payment for Telehealth Services

February 4th, 2013

If you are participating in Telehealth services, you have eight new services for which you can bill:

G0396      Alcohol and/or substance (other than tobacco) abuse structured assessment (for example, AUDIT, DAST) and brief intervention, 15 to 30 minutes

G0397      Alcohol and/or substance (other than tobacco) abuse structured assessment (for example, AUDIT, DAST) and intervention greater than 30 minutes 

G0442      Annual alcohol misuse screening, 15 minutes

G0443      Brief face-to-face behavioral counseling for alcohol misuse, 15 minutes.

G0444      Annual Depression Screening, 15 minutes.

G0445      High-intensity behavioral counseling to prevent sexually transmitted infections, face-to- face, individual, includes: education, skills training, and guidance on how to change sexual behavior, performed semi-annually, 30 minutes.

G0446      Annual, face-to-face intensive behavioral therapy for cardiovascular disease, individual, 15 minutes

G0447       Face-to-face behavioral counseling for obesity, 15 minutes.

Telehealth services require providers to have a video telecommunications system that allows the communication between the originating site and distant site in "real time."  If requirements are met, many services besides those listed above may be billed including evaluation and management services,

For details on Telehealth visit:



Tags: Telehealth


Have You Reviewed Your Withholding Lately?

November 20th, 2012

We may not yet know whether or not the Bush tax cut will be extended; but there are other reasons to review your withholding.

Following please find an article from Charles Auerbach, CFP®, CLU, ChFC, EA of Memphis's Wealth Strategies Group, Inc.:

As 2012 turns into 2013, there are some important things to consider.

Payroll taxes are slated to increase 2 percent next year. The payroll tax cut of 2011-12 has slim chance of extending into 2013. The maximum payroll tax paid by high earners is slated to be $7049.40 next year, $2,425 above 2012 levels. That isn't just because Social Security taxes for employees are returning to the 6.2 percent level; it also reflects a 3.3 percent increase in the upper salary limit subject to the tax to $113,700.

Now is a good time to review your withholding status. Aside from the presumed end of the payroll tax holiday, there are other reasons you may want to adjust your withholding status.

1. You tend to pay a great deal of income tax each year.
2. You tend to get a big federal tax refund each year.
3. You recently married or divorced.
4. A family member recently passed away.
5. You started a business venture or became self-employed.

Source: www.forbes.com_sites_janetnovack_2012_10_16_social-security-benefits-to-rise-1-7-workers-face-up-to-2425-payroll-tax-hike(10.16.12)

Tags: Taxes


New Waived Tests

October 2nd, 2012

The Food and Drug Administration has added to its list of tests that may be performed under a CLIA Waiver.  For the full list visit:

The complete list may also be found on the CMS website at:

Even if a physician's office performs only waived tests, it is still necessary to have a CLIA number; and to follow good laboratory practices.

The Centers for Disease Control has publushed a booklet on Good Laboratory Practices for Waived Testing Sites.  It may be downloaded at:

Tags: Waived Tests


EHR: Potential Mining Disaster?

September 27th, 2012

EHR products can make it so easy to create a nice long note about patient care.

Frequently all a provider must do is cut, paste and modify.  Based on the information provided, the software then suggests a higher code than you would have been paid under the old system.

How great is this?  Incentive money and higher average charges too!

But beware!  If your average level of service has increased from what it was without EHR, you run a real risk of being "data mined" and audited. 

Remember medical necessity underlies all documentation!  The length and detail of your note is irrelevant if you there if the medical necessity for services performed is not clear.

Five major Hospital Associates were sent a sternly worded letter by Kathleen Sebelius, Secretary of HHS and Eric Holder, US Attorney General,  warning about the misuse of electronic health records to upcode.

In part the letter reads:

False documentation of medical care is not just bad medical care; it's illegal.  These indications include potential "cloning" of medical records to inflate what providers get paid.

The letter details some of the new administrative tools available to mine data and pursue those suspected of fraud.

The letter continues:

We will not tolerate health care fraud.  The President initiated in 2009 an unprecedented Cabinet-level effort to combat health care fraud and protect the Medicare trust fund; and we take those responsibilities very seriously.

Law enforcement will take appropriate steps to pursue health care providers who misuse electronic health records to bill for services never provided.

Scarey stuff.  Be careful out there.  Let medical necessity dictate what is done; and code accordingly.  IGNORE the codes suggested by your EHR!

Tags: EHR, Fraud, Upcoding


Back To Basics - Observation Care Coding

September 18th, 2012

One of the main jobs of a medical billing company is dealing with denials!


Sometimes, there are “trends” that call for further investigation; and sometimes we find out that our clients have some basic misunderstandings on how to bill for the services they render.  Sometimes we find that even we need a refresher on the rules!


Observation care is just such a set of codes.


Some fairly unknown basics:


  • Observation care is always an OUTPATIENT service.
  • Only one physician can bill for Observation care per day.  That should be the physician who is the “admitting” physician UNLESS he transfers care to a specialist.
  • Any other physicians involved in the care while a patient is in the observation unit should bill the appropriate OUTPATIENT service code…usually the same codes that you would bill for in office services.
  • A physician who does not have admitting privileges at a hospital; but who may see patients at the hospital in an outpatient capacity MAY bill for observation care.
  • Observation care is billed by calendar day NOT by twenty-four hour period.
  • If a patient is admitted to observation care for less than 8 hours on the same calendar date, the Initial observation care from CPT code range 99218 – 99220, should be reported.. The physician should NOT bill the Discharge Code even if the patient is discharged.
  • If a patient is in Observation care for at least 8 hours, but less than 24 hours, and is discharged on the same calendar date, Observation or Inpatient Care Services (Including Admission and Discharge Services) from CPT code range 99234 – 99236 shall be reported. CPT code 99217 for Observation Discharge cannot also be reported. This can be confusing.  These services are still OUTPATIENT despite the name of the code.
  • Per CMS “On the rare occasion when a patient remains in observation care for 3 days, the physician shall report an initial observation care code (99218-99220) for the first day of observation care, a subsequent observation care code (99224-99226) for the second day of observation care, and an observation care discharge CPT code 99217 for the observation care on the discharge date. When observation care continues beyond 3 days, the physician shall report a subsequent observation care code (99224-99226) for each day between the first day of observation care and the discharge date.”  Remember, if there are two doctors attending to the patient, only the physician primarily in charge of the care may bill for observation.  The other should use other outpatient service codes.
  • When a patient is admitted for observation care one calendar day and is discharged on a different calendar date, the physician shall report Initial observation care, from CPT code range 99218 – 99220, and CPT observation care discharge CPT code 99217.
  • If the same physician admitted the patient to observation care later admits the patient to inpatient on the same calendar day he has provided observation care, the physician should only bill for the initial hospital visit for the evaluation and management services provided on that date.  Be sure to incorporate the notes from observation by reference in your inpatient record.  Also, in appropriate cases, a physician may add prolonged attendance codes.  If so, be sure your time is documented.
  • In order to bill observation care codes, there must be a medical observation record for the patient which contains dated and timed physician’s orders and progress notes about the services the patient received and nursing notes. This record must be in addition to the records of ED or in-office visits.
  • Per CMS guidelines, “in only rare and exceptional cases do reasonable and necessary outpatient observation services span more than 48 hours. In the majority of cases, the decision whether to discharge a patient from the hospital following resolution of the reason for the observation care or to admit the patient as an inpatient can be made in less than 48 hours.”


For more detail and examples on billing for observation services, visit the CMS Manual System at:

Tags: Observation Care


Do You Need A Nurse?

August 20th, 2012

With Medicare breathing down the necks of hospitals to reduce readmission rates, it might be time to revisit your clinical management to ensure that you have right staff to handle the “fun” coming our way.

If a patient is being discharged from the hospital with home healthcare it will be the home health nurse who is responsible for communicating to you that patient’s condition.  Home health nurses operate on the front line and are an extension of your practice.   Therefore, your ability to direct patient interventions in a timely manner is essential.  Often, home health nurses contact a physician’s office to report adverse findings only to be transferred voice mail that is checked twice daily handed or transferred to medical assistant that may or may not understand the gravity of the situation such as a 7 pound weight gain in 24 hours.

Many practices determined that registered nurses or licensed practical nurses were a financial burden to the bottom line of a physician’s practice.   In most cases, Medical assistants were perfectly capable of handling the mundane tasks as appointments, prescription refills and patient vital signs. 

But with the Medicare’s landscape changing, nurses could prove to be valuable and necessary again by

  • spending the necessary time with patients educating them on their diets and medications, and
  • relaying important information from home health nurses who need your medical intervention NOW, not four hours from now when the patient has gone back to the ED. 

If we are to weather Medicare’s newest cost saving measure it will be imperative that the primary care physician be easily accessible to avoid a patient returning to the ED.

Let’s face it-you don’t want to talk to each and every nurse that calls in a temperature of 99 degrees and a blood pressure of 165/80.  Having a nurse in your office with a solid clinical background that can prioritize information, contact patients and guide patient care at your direction could prove to be an invaluable tool to improving your patient outcomes. 

Medicare’s has requested new reimbursable codes for 2013 for a physician following-up on a patient for thirty days after he has left the hospital or a long-term care facility even if a home health agency is not involved.  Having a nurse could provide an invaluable link in providing care with our without home health agency involvement?

Tags: Compliance, Home Health,

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Hospitals Penalized for Readmission Rates

August 13th, 2012

Medicare has published the list of hospitals that will face penalties because of high readmission rates beginning October, 2012; and many familiar names are on the list.

To see if the hospitals you use are on the list, visit:  Hospitals with 2013 Medicare Reductions

According to an article in Kaiser Health News, hospitals that serve the poor were hit harder than others.  Per Kaiser's article:  "The analysis of the penalties shows that 76 percent of the hospitals that have a lot of  low-income patients will lose Medicare funds in the fiscal year starting in October. Only 55 percent of the hospitals treating few poor patients are going to be penalized, the analysis shows.

Medicare disagrees that "safety-net hospitals" were disproportionately penalized writing:  "many safety-net providers and teaching hospitals do as well or better on the measures than hospitals without substantial numbers of patients of low socioeconomic status."

Per KLA's experience in this area, providers that serve the poor frequently have no choice but to readmit a sick patient who has been delivered to their office by relatives or friends who cannot nor will not further care for the patient.

With penalties being applied to hospitals regardless of the reason for readmission, providers must find alternatives to hospital stays for their poor patients; or face growing pressure from the hospital systems who are being penalized for readmissions.

CMS has proposed offering to pay providers for coordination of care thirty days after the patient leaves the hospital or skilled nursing facility.  (See our July 7 blog post for details.)

Tags: Readmission, Inpatient, Hospital


Send Referrals Instantly from Practice Fusion

August 1st, 2012

Sending referrals is a huge headache for many primary care providers.  Practice Fusion has just announced that by the end of this week its users will be able to send them by fax or email instantly.

If you would like to try this FREE EHR which helped more doctors receive meaningful use than any other, sign up at:

As for instant referrals, per Practice Fusion's Instructions:

,,, Our upcoming release includes new instant referrals that allow you to refer patients directly to another provider within the EHR and receive confirmation instantly.

Completely HIPAA-complaint for sensitive patient information (unlike emailed e-referrals), instant referrals saves you time while taking the guesswork out of the medical referral process for you and your patients.

To send an instant referral:

  1. From a SOAP note or the Patient Actions menu, select Send referral / response letter
  2. Choose a recipient from your recipient list, or select Add New Recipient to create a new contact
  3. Review the referral information, then click Send instantly (see below)

The patient referral will automatically be sent to your colleague, who will receive an email and a fax notification that a referral is waiting in the EHR. Practice Fusion users will receive the patient referral instantly while in the EHR.

Instant referrals can be sent to anyone in your existing fax referral recipient list, and are part of your existing medical referral workflow if you’ve used our referrals feature in the past.

To access your patient referral:

  1. Click on the Your Network tab to the right. Select your colleague’s name.
  2. You’ll see your patient’s name linked in the conversation window. Simply click on it to view the referral.
  3. You can also send your colleague a follow-up message from this window.

In order to quickly bring you this new functionality, we’ve had to streamline the referral screen. You will no longer see the Dx and Rx Add/Remove buttons or vital signs. To customize your patient referral, switch to a simple referral letter by deselecting Include patient data at the bottom.

While the referral screen has been temporarily streamlined, patient referrals will soon be even more customizable for you. We’re working hard to bring you the ability to add full chart notes directly into your referrals, so stay tuned!

Tags: EHR, Practice Fusion, Referrals


Back to Basics: Can I Charge My Nurse's Services?

July 26th, 2012

The question is one of the most common we hear.  Can I bill for ???? if my RN/LN does it?

The short answer almost every time is, "I don't know, but I'll find out."

CMS calls this the "level of supervision."

The level of supervision required for each service is published by CMS as a part of the Medicare Physician Fee Schedule Database.  To determine the level of supervision for a specific HCPCs or CPT code, please refer to fee schedule look up page of the CMS website at the following address:

To locate the supervision level for your code(s) from this website you will need to enter the following information in the sequential screens:

Step 1

  • Select the appropriate year;
  • Select a single, list (up to 5) or a range of procedure codes;
  • Select “Payment Policy Indicators”
  • Select the “Next” button

Step 2

  • Select “Default fields”;
  • Select the “Next” button.

Step 3

  • Enter the HCPC(s) you are researching
  • Select one of the available modifiers or select “all modifiers”
  • Select the “Next” button

The code you have selected will appear on the next page with the corresponding MPFSDB payment policy indicators including “phys supv.”

The numerical indicator will explain the level of physicians supervision needed:  There are basically three levels of physician supervision according to Section 410.32(b) of the Code of Federal Regulations.  They are:

General supervision means the procedure is furnished under the physician’s overall direction and control, but the physician’s presence is not required during the performance of the procedure. Under general supervision, the training of the nonphysician personnel who actually performs the diagnostic procedure and the maintenance of the necessary equipment and supplies are the continuing responsibility of the physician.

Direct supervision in the office setting means the physician must be present in the office suite and immediately available to furnish assistance and direction throughout the performance of the procedure. It does not mean that the physician must be present in the room when the procedure is performed.

Personal supervision means a physician must be in attendance in the room during the performance of the procedure.

If the level of supervision required is not met, the service will not be considered reasonable and necessary for Medicare payment purposes.

You will need a "key" to understand the number associated with "phys supv" in the fee schedule. The numbers mean:

  • 1 Procedure must be performed under the general supervision of a physician.
  • 2 Procedure must be performed under the direct supervision of a physician.
  • 3 Procedure must be performed under the personal supervision of a physician.
  • 4 Physician supervision policy does not apply when procedure is furnished by a qualified, independent psychologist or a clinical psychologist or furnished under the general supervision of a clinical psychologist; otherwise must be performed under the general supervision of a physician.
  • 5 Physician supervision policy does not apply when procedure personally furnished by a qualified audiologist; otherwise must be performed under the general supervision of a physician.
  • 6 Procedure must be personally performed by a physician OR a physical therapist who is certified by the American Board of Physical Therapy Specialties (ABPTS) as a qualified electrophysiologic clinical specialist and is permitted to provide the service under State law.
  • 6a Supervision standards for level 66 apply; in addition, the PT with ABPTS certification may supervise another PT but only the PT with ABPTS certification may bill.
  • 9 Concept does not apply.
  • 21 Procedure must be performed by a technician with certification under general supervision of a physician; otherwise must be performed under direct supervision of a physician.
  • 22 May be performed by a technician with on-line real-time contact with physician.
  • 66 Procedure must be performed by a physician or by a PT with ABPTS certification and certification in this specific procedure.
  • 77 Procedure must be performed by a PT with ABPTS certification or by a PT without certification under direct supervision of a physician, or by a technician with certification under general supervision of a physician.
  • 7a Supervision standards for level 77 apply; in addition, the PT with ABPTS certification may supervise another PT but only the PT with ABPTS certification may bill.
  • 0 Procedure is not a diagnostic test or procedure is a diagnostic test which is not subject to the physician supervision policy.




Tags: Level of Supervision, Nurse Services,


New Interventional Pain Management Law in Tennessee

July 25th, 2012

If you have a pain management practice in Tennessee, don't miss the latest legislation as presented by Memphis Healthcare Attorney, Charles Key:


Clients and Friends:
(Following are the highights from a) new piece of Tennessee legislation I thought would be of interest to you, 2012 Tenn. Public Chapter 961. 
Public Chapter 961 adds new language to Tenn. Code Title 63 (which governs the licensing and regulation of health professionals) that:


  • Creates a defined term, "interventional pain management," meaning "the practice of performing invasive procedures involving any portion of the spine, spinal cord, sympathetic nerves of the spine[,] or block of major peripheral nerves of the spine in any setting that is not [a licensed health care facility, e.g., a hospital, ASC, or nursing home under Tenn. Code Ann. Title 68]."


  • Requires that advance practice nurses (e.g., nurse practitioners, CRNAs) and physician assistants perform interventional pain management procedures only under the direct supervision of a physician who has the following qualifications and is physically present in the same building during the time the procedure is performed by the nurse practitioner:  a Tennessee-licensed MD or DO "actively practicing spinal injections" current privileges to give spinal injections at a Tennessee-licensed health care facility board certified in anesthesiology, neurosurgery, neuromusculoskeletal medicine, orthopedics, physiatry, radiology, or other ABMS subspecialty board in pain medicine, has completed an ACGME-accredited pain fellowship, or is board certified in a different ABMS or ABPS/AAPS specialty and has completed a post-graduate training program in interventional pain management approved by the medical or osteopathic licensing board.


  • Recognizes exceptions for "major joint injections" other than sacroiliac injections, soft tissue injections or epidurals for surgical anesthesia or labor analgesia.

The new law is effective July 1, 2013.
Charles M Key
Wyatt, Tarrant & Combs, LLP
The Renaissance Center
1715 Aaron Brenner Dr., Suite 800
Memphis TN 38120-4367
Direct: (901) 537-1133
Mobile: (901) 481-3321
Fax: (901) 537-1010
Email: ckey [at] wyattfirm [dot] com

Tags: Pain Management


Modifier 59 - Friend and Foe

July 16th, 2012

While reviewing an inappropriate denial for two codes as "bundled," I went to the's own CCI information for documentation.

Much to my wandering eyes' amazement, I noticed an article on Modifier 59.  It was the ONLY article on any modifier on the page.  Hmmm?

Coders know, Modfier 59 is a wonderful way to help get a claim paid.  CPT® Guidelines tell us that the modifiershould be used if a procedure or service was distinct or independent from other services performed on the same day. 

This could mean

  1. a different session or patient encounter,
  2. a different procedure or surgery,
  3. a different site or organ system,
  4. or a separate incision/excision.

If one of the four is true, two codes that were once "bundled," may be unbundled.  Both will be paid with the addition of modifier 59.

Unfortunately, many practices' AR staffs are so concerned with getting in every dollar that they add modifer 59 WHETHER OR NOT one the four criteria above has been met.   Although this will mean extra dollars in your pocket, if used too frequently you may be cherry picked as an outlier for a Medicare audit.

As the ONLY modifier specifically discussed on Medicare's CCI page, this is clearly of concern! 

You may read CMS's article yourself at:

Tags: Modifier 59, CCI (Correct Coding Initiative)


CMS Proposes Pay Increase for Family Practitioners, Primary Care & Pay for 30 Days of Coordination of Care for Transition from Hospital

July 7th, 2012

Yesterday CMS released its proposed 2013 rule.

As before, CMS is favoring primary care providers with proposed increases.  In addition, for the first time, CMS proposes to pay for coordination of care for thirty days after a patient leaves the hospital or nursing facility.

The entire press release is reproduced below:


The Centers for Medicare & Medicaid Services (CMS) today issued a proposed rule that would increase payments to family physicians by approximately 7 percent and other practitioners providing primary care services between 3 and 5 percent.  The increase in payment to family practitioners is part of the proposed rule that would update payment policies and rates under the Medicare Physician Fee Schedule (MPFS) for calendar year (CY) 2013.  Under the MPFS, Medicare pays more than 1 million physicians and nonphysician practitioners that provide vital health services to Medicare beneficiaries. 

“Helping primary care doctors will help improve patient care and lower health care costs long term,” said CMS Acting Administrator, Marilyn B. Tavenner. 

The 7 percent increase for family physicians comes from a proposal that continues the Administration’s policies to promote high quality, patient-centered care.  For CY 2013, CMS is proposing for the first time to explicitly pay for the care required to help a patient transition back to the community following a discharge from a hospital or nursing facility. The proposals calls for CMS to make a separate payment to a patient’s community physician or practitioner to coordinate the patient’s care in the 30 days following a hospital or skilled nursing facility stay.  The proposed rule also asks for public comment on how Medicare can better recognize the range of services community physicians and practitioners provide as part of treating patients either through face-to-face services in the office or coordinating care outside the office when the patient does not see the physician.

As has been the case every year since CY 2002, CMS projects a significant reduction in MPFS payment rates under the Sustainable Growth Rate (SGR) methodology due to the expiration of the adjustment made for CY 2012 in the statute.  For CY 2013, CMS projects a reduction of 27 percent and is required by law to include this reduction in these calculations. However, Congress has acted to avert the cuts every year since 2003.  The Administration is committed to fixing the SGR formula in a fiscally responsible way.

The proposed rule would also continue the careful implementation of the physician value-based payment modifier (Value Modifier) that was included in the Affordable Care Act by providing choices to physicians regarding how to participate.  The Value Modifier adjusts payments to individual physicians or groups of physicians based on the quality of care furnished to Medicare beneficiaries compared to costs.  The law allows CMS to phase in the Value Modifier over three years from CY 2015 to CY 2017.  For the CY 2015 physician payment rates, the proposed rule would apply the Value Modifier to all groups of physician with 25 or more eligible professionals.  The proposed rule also provides an option for these groups to choose how the Value Modifier would be calculated based on whether they participate in the Physician Quality Reporting System (PQRS).  For groups of 25 or more that do not participate in the PQRS, CMS is proposing to set their Value Modifier at a 1.0 percent payment reduction.  For groups that wish to have their payment adjusted according to their performance on the value modifier, the rule proposes a system whereby groups with higher quality and lower costs would be paid more, and groups with lower quality and higher costs would be paid less. The performance period for the CY 2015 Value Modifier was established as CY 2013 in the MPFS Final Rule for CY 2012. 

The proposed rule continues efforts by CMS to align quality reporting across programs to reduce burden and complexity. The proposed rule proposes changes to two quality reporting programs that are associated with the MPFS – the PQRS and the Electronic Prescribing (eRx) Incentive Program – as well as the Medicare Electronic Health Records (EHR) Incentive Pilot Program which promotes the use of health information technology.  The PQRS proposal includes simplified, lower burden options for reporting and the proposed rule aligns quality reporting across the various programs in support of the National Quality Strategy.  The proposed rule also addresses the next phase in a plan to enhance the Physician Compare Website to foster transparency and public reporting of certain information to give beneficiaries more information for purposes of choosing a physician.

The proposed rule also includes:

  • A proposal to include additional Medicare-covered preventive services on the list of services that can be provided via an interactive telecommunications system;
  • A proposal to implement a durable medical equipment (DME) face-to-face requirement as a condition of payment for certain high-cost Medicare DME items;
  • A proposal to apply a multiple procedure payment reduction (MPPR) policy to the technical component of the second and subsequent cardiovascular and ophthalmology diagnostic services furnished by the same doctor to the same patient on the same day;
  • A proposal to collect data on patient function to improve how Medicare pays for physical and occupational therapy, and speech language pathology services;
  • A request for public comments on payment for advanced diagnostic molecular pathology services;
  • A proposal to revise a regulation that only allows Medicare to pay for portable x-rays ordered by an MD or DO.  The revised regulations would allow Medicare to pay for portable x-ray services ordered physicians and non-physician practitioners acting within the scope of their Medicare benefit and state law;
  • A proposal to clarify when Medicare will pay for interventional pain management services provided by Certified Registered Nurse Anesthetists (CRNAs) when permitted by State law.  This proposal will foster access to pain management services in areas where states have determined that CRNAs may provide these services.

The proposed rule will appear in the July 30, 2012 Federal Register.  CMS will accept comments on the proposed rule until Sep. 04, 2012, and will respond to them in a final rule with comment period to be issued by Nov. 1, 2012.

For more information, see:

Tags: 2013 CMS Rule, Coordination of Care


ACA Upheld as Tax -- Taxes, Taxes Everywhere!

July 2nd, 2012

Thanks to our friend Charles Auerbach for this excellent update on what SCOTUS's recent holding means from a financial planning point of view.

What Does the Supreme Court Ruling on the Health-Care Reform Law Mean for You?

On June 28, 2012, the U.S. Supreme Court ruled, in a landmark decision, that the Patient Protection and Affordable Care Act (ACA), including the provision that most Americans carry health insurance or pay a penalty, is constitutional.

The ACA, signed into law in 2010, made sweeping reforms to health-care coverage in the United States. Many provisions of the law have already taken effect. A number of other provisions are scheduled to take effect in subsequent years, including the requirement that most Americans and legal residents have qualifying health insurance (exceptions apply) or pay a penalty in the form of a tax. Here's a summary of some of the important provisions that are already in place, and those that are on their way by 2014.

In effect now

  • Children can no longer be denied insurance coverage because of pre-existing conditions
  • Payment of $250 rebate to Medicare Part D beneficiaries subject to the coverage gap (beginning January 1, 2010) and gradually reducing the beneficiary coinsurance rate in the coverage gap from 100% to 25% by 2020
  • Insurers will not be able to impose lifetime caps on insurance coverage
  • All plans offering dependent coverage will be required to allow children to remain under their parents' plan until age 26
  • Insurers cannot cancel or deny coverage if you are sick except in cases of fraud
  • Adults with pre-existing conditions will be able to buy coverage from temporary high-risk pools until 2014, when coverage cannot otherwise be denied for pre-existing conditions

Key provisions effective on or before January 1, 2014

  • Increasing the medical expense income tax deduction threshold to 10% of adjusted gross income, up from the current 7.5% (January 1, 2013)
  • Increasing the Medicare Part A tax rate by 0.9% on wages over $200,000 for individuals ($250,000 for married couples), and assessing a new 3.8% tax on some or all of the net investment income for these higher-income individuals (January 1, 2013)
  • All Americans must carry health insurance or face a penalty (in the form of a tax) of up to 2.5% of household income on individuals, with exceptions for economic hardship, religious beliefs, and other situations (January 1, 2014)
  • Adults with pre-existing conditions cannot be denied coverage or have their insurance cancelled due to pre-existing conditions (January 1, 2014)
  • A requirement that states establish an American Health Benefit Exchange that facilitates the purchase of qualified health plans and includes an Exchange for small businesses; also requires employers that contribute toward the cost of employee health insurance to provide free choice vouchers to qualified employees for the purchase of qualified health plans through Exchanges (January 1, 2014)
  • Tax credits will be available to qualifying families to offset the cost of health insurance premiums (January 1, 2014)
  • Employers with more than 50 employees must offer health insurance for their employees or be fined per employee (January 1, 2014)
  • Imposing taxes or fees on health insurance providers and drug companies, while doctors and hospitals will receive less compensation from government sources (January 1, 2014)

So is this it?

While the Supreme Court has ruled the ACA constitutional, it may still face challenges as Congress may seek to repeal the law. The ultimate fate of the health-care reform law may be determined by the outcome of the November elections.

Wealth Strategies Group, Inc.

When life changes, call us.
Charles Auerbach, CFP®, CLU, ChFC,EA
8001 Centerview Parkway
Suite 201
Cordova, TN 38018
901-473-9000 ex: 204
charlie.auerbach [at] natplan [dot] com

Tags: Affordable Care Act


AMA Educates On New Payment Options: Meet Your New Options, Same as Your Old Options?

June 22nd, 2012

One thing we can say for sure about the last few years...there's been lots of changes. 

KLA joins many of our clients with nervousness as to what the future of healthcare reimbursement holds.  We are faced every year with the prospect of HUGE cuts in Medicare.  Rumors are rampant as to what the new models will look like.  Hospitals are working to establish ACOs.  Healthcare plans are establishing systems where doctors are reimbursed NOT to provide care.  We are having trouble even keeping up with the acronyms.

And no one in our office is psychic!

To the rescue, the AMA.  If you don't know the difference between Capitation, Risk Pools and Shared Savings, the AMA has the answer for you.

According to the AMA website:

A "how-to" manual from the AMA helps physicians evaluate, negotiate and manage these new budget-based payment systems. Developed with input from experts in physician payment issues, the manual, "Evaluating and Negotiating Emerging Payment Options," analyzes each payment option and provides essential information and practical tools that can help physicians:

  • Understand how budget-based payment systems differ from fee-for-service.
  • Master concepts associated with budget-based systems, including actuarial soundness, risk adjustment and risk mitigation.
  • Estimate, monitor and manage the financial risks and rewards of a budget-based payment system.

A brief introductory webinar offers an overview of the manual, and a more in-depth webinar details each chapter. The manual will be expanded and updated regularly to provide physicians with the latest information and tools on emerging payment arrangements.

"Evaluating and Negotiating Emerging Payment Options" is just one of many resources available free to all physicians on the AMA's online practice consultant. The AMA also offers related resources about ACOs; Consumer Operated and Oriented Plans, known as CO-OPs; and other new delivery system options.

(End of quote)

These are well researched and documented resources that help cut through the rumor mill and understand the various payment options being visited.

Truthfully, for those of us with a couple of decades in the business, most of these new payment options seem much like the same old payment options (that have been tried and failed before); wrapped up in new initials and verbage.

Tags: AMA, Accountable Care Organizations, Emerging Payment Options


Incident To and Shared/Split Services - Effectively Billing for Non Physician Providers

June 17th, 2012

If you use NPPs (non-physician practitioners) in your practice, learn the rules for appropriate billing; or face possible recoupment or even false claim charges! 

Really, this is serious!

Misuse of “incident to” billing has been identified by auditors as a concern so many times, that scrutinizing the incident to services is AGAIN part of the HHS Office of Inspector General’s 2012 Work Plan.  “Incident to” was also scrutinized by the OIG in 2001, 2003, 2004, 2007, 2008 and 2009.

What Is “Incident To” and When Can You Bill It?

In a physician’s office, qualified NPPs can treat certain patients and still bill the visit under the physician's National Provider Identifier (NPI).  If billed under the physician’s NPI, the NPP is invisible and the practice will be paid physician rates instead of NPP rates which typically are fifteen percent (15%) lower.

CMS' Benefit Policy Manual defines "incident to" as "services furnished as an integral although incidental part of a physician's personal professional service."   To qualify as “incident to”

1. The NPP must perform the service in a physician's office (place of service 11).

2. The NPP must perform the service within the scope of the practice and in accordance with state law.  (Check your state board.)

3. The physician must establish the care plan for the new patient to the practice or any established patient with a new medical condition. NPPs may implement the established plan of care.  If the physician has not seen the new patient or evaluated the new condition, billing must be under the NPP’s NPI.  The physician must remain actively involved in the care of the patient.

4. The physician must be on site when the NPP is rendering the service.

You CANNOT bill Medicare for “incident to” in a hospital setting -- either outpatient, inpatient, or in the emergency department -- as incident-to. Medicare doesn't allow it.

For more information on “incident to” see:  the Medicare Claims Processing Manual (MCPM), Chapter 12, Section 30.6.1.B,  Medicare Benefit Policy Manual, Chapter 16, Section 60 and MLN Matters Number: SE044.

If Using a NPP in Hospital, Examine the Share/Split Rules

Although “incident to” is not allowed in facility settings, there are other rules that will allow a share/split of a visit between a physician and NPP.

When a physician provides services in the hospital, he may opt to share the work with a non-physician practitioner (NPP) to provide high quality services in minimal time. Not understanding these rules can cost a practice 15 percent every time he bills under a NPP instead of a physician.  . Make sure you're bringing in every dollar by learning these three split/shared visit guidelines.

Understand Shared Visit Rules

Split/shared rules come into play when one of your physicians and a qualified nonphysician practitioner (NPP), such as a nurse practitioner or physician assistant, each see a patient face to face in the hospital. Each provider performs a distinct part of an E/M service.

If the encounter meets shared visit guidelines, you may report the entire visit under your physician's National Provider Identifier (NPI) and be allowed 15 percent more for the same service.

As with incident-to services, a practice receives 100 percent of the Medicare allowable for the physician when services are reported under NPI. The same service under the NPP's NPI, will be allowed at 85 percent of the Medicare fee.

To bill a shared visit under the physician's NPI, a physician must provide and document a face-to-face service for the patient. The hospital records should include:

  • Documentation by the physician and the NPP of services supporting the E/M level billed.
  • A clear indication as to which services were provided by which provider (the NPP and physician.)
  • A reference in the physician's documentation that the NPP’s services were reviewed and approved noting any exceptions or additions to approval.
  • The physician's and NPP's documentation must indicate a face-to-face encounter with the same patient on the same day in the hospital
  • Legible (or approved electronic) signatures of the physician and NPP providing the E/M must be included.

The physician must ALWAYS perform and document at least part of the E/M visit in a facility setting.  Direct patient face-to-face contact is mandatory for shared services.

An example provided by Medicare of acceptable billing for a shared service is:

If the NPP sees a hospital inpatient in the morning and the physician follows with a later face-to-face visit with the patient on the same day, the physician or the NPP may report the service.

Split Billing Still an Option

In MLN Matters article SE1010, CMS notes that "the split/shared rules applying to E/M services remain in effect, including those cases where services would previously have been reported by CPT consultation codes."  In the past, you could not report the consultation codes as a split/shared visit as the physician alone could formulate the initial treatment plan.

You could, however, bill the codes now used for consultations (99221-99223 and 99231-99232) as a split/shared visit, allowing the physician full pay when he shared the work for this patient with an NPP. 

The best practice for hospital claims that would have been treated as consultation is the past, is for the physician to perform and document all elements of the E/M service because it is the expertise of the consultant that is sought by another provider.

Although CMS guidance does appear to allow split/shared billing for the codes now being used for consultation, the rules on split/shared E/Ms exclude consultations (and intensive care and procedures) from split/shared coverage.  Consultants were to evaluate all new patients and new problems. If, however, the consultant assumes part of the care for the patient, he is no longer acting as a consultant.  Thus, he may use NPPs under the splite/shared billing rule.

Per CMS Transmittal 1875:

A split/shared E/M visit is defined by Medicare Part B payment policy as a medically necessary encounter with a patient where the physician and a qualified NPP each personally perform a substantive portion of an E/M visit face-to-face with the same patient on the same date of service. A substantive portion of an E/M visit involves all or some portion of the history, exam or medical decision making key components of an E/M service. The physician and the qualified NPP must be in the same group practice or be employed by the same employer. The split/shared E/M visit applies only to selected E/M visits and settings (i.e., hospital inpatient, hospital outpatient, hospital observation, emergency department, hospital discharge, office and non facility clinic visits, and prolonged visits associated with these E/M visit codes). The split/shared E/M policy does not apply to consultation services, critical care services or procedures.


In summary, assuming the physician has assessed new patients and new problems, has remained involved in a patient’s care and has properly documented the services; a NPP’s services may be billed under the physician’s NPI:

In the office:  When the physician is on the premises at the same time.

In the hospital:  When the physician sees and is involved in patient care ON THE SAME DAY.  Exceptions:  consultations, critical care and procedures.

Please note the discussions above relate to Medicare rules. Be sure to check with your commercial carriers to see if they follow the same rules.

Tags: Incident to, Shared/Split Services


Billing for the Inquisitive Patient

June 11th, 2012

All providers have at least one:  the inquisitive patient. 

Within minutes of entering the room, you have performed a sufficient history and physical and made your medical decision.  You are ready with a likely diagnosis and course of treatment.

Your patient, however, has spent much time self-diagnosing with online symptom checkers.  He came prepared with a folder full of his own research. 

Thus the majority of the visit is not involved with diagnosis and treating the patient.  Instead it is involved in explaining to the patient why it is unlikely he has blisters from  Paraneoplastic Pemphigus and more likely he has them from ill-fitting shoes.

The AMA’s CPT discusses billing based on time when counseling and/or coordination of care predominate an encounter.  CMS, does not always follow the AMA guidelines, but in this case, it does.

On page 3 of CMS’s 1995 Documentation Guidelines, CMS tells us:

An exception to this rule (of determining service level based on 3 key components)  is the case of visits which consist predominantly of counseling or coordination of care; for these services time is the key or controlling factor to qualify for a particular level of E/M service.

Likewise on page 4 of  CMS’s 1997 Documentation Guidelines, there is guidance on what to do in this situation:

In the case of visits which consist predominantly of counseling or coordination of care, time is the key or controlling factor to qualify for a particular level of E/M service.

Thus CMS HAS provided you a way to bill for your time when you have an inquisitive patient. 

In order to bill for time, ensure the following are noted in your records:

1. The time spent face-to-face with the patient.  Ideally you will record start and stop time.

2. In the office, document that more than half of the face-to-face time was spent with the patient/and or family is counseling/coordination of care. For instance, "Saw the patient for 10:00 to 10:25 a.m. face-to-face; 20 minutes of that visit was spent in counseling.”  The rule is slightly different for an inpatient setting.  You may include time in the unit or floor when directly involved with the care of the patient.

3. A description or summary of the counseling/coordination of care provided.

Selecting the Proper Code

The CPT description of most evaluation and management codes include descriptions of the level of history, physical and medical decision making.  The codes will also include the amount of time a provider “typically” spends with the patient.  This is the time used to select the code.

The code selection is based on the total time of the encounter, not just the time involved in counseling/coordination of care. But counseling/coordination of care must exceed 50% of the encounter.   The medical record must contain the details listed above to justify the selection of the specific code if time is the basis for selection of the code.

Note that not ALL evaluation and management codes contain times.  For example, billing based on time in the emergency department is not an option since time is not included as a component of those codes.

Office or Other Outpatient Setting

In an office setting, the patient must be present when counseling and/or coordination of care services are rendered.. Face-to-face time refers to the time with the provider only. Counseling by other staff is not considered to be part of the face-to-face physician/patient encounter time. Therefore, the time spent by the other staff is not considered in selecting the appropriate level of service. The code used depends upon the provider service provided.  This is NOT an appropriate use of “incident to” for

Inpatient Setting

Counseling and/or coordination of care must be provided at the bedside or on the patient’s hospital floor or unit and be for the specific patient. Time spent counseling the patient or coordinating the patient’s care after after the provider has left the patient’s unit or begun to care for another patient in the unit should not be included in total time supporting the level of service.

Medical/Legal Consideration

Many providers practice “most likely scenarios” when treating patients with strict instructions to call back if there isn’t improvement or if certain new symptoms manifest.  When dealing with a patient with a handful of web articles and billing for counseling/coordination of care; be sure to take the time to document your differential diagnoses.  In the extremely rare case where the patient’s research is right, the standard is not whether you were right or wrong; but whether or not you were “negligent” with you diagnosis.

Tags: Counseling/Coordination of Care, Billing by Time, Documentation, Evaluation and Management


Yes Virginia, You CAN Bill Both

June 8th, 2012

Yes, you CAN bill for a preventive and sick patient services on the same day!

Initially, CMS wanted preventive services to be billed on separate days from sick patient visits; but the final rule ALLOWS both to be billed. 

But be careful.  It is unlikely that you can bill a high level sick visit and a preventive service on the same day.  History and exam elements that are part of the preventive service CANNOT be double counted!  Thus, if the elements are part of the preventive service, they are NOT part of the sick patient service.

CPT says you can bill both well patient and sick patient on the same day IF the problem "is significant enough to require additional work to perform the key components of a problem-oriented E/M service." Append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the evaluation and management code.

Ideally the provider will document the visits separately.

NO CoPays or CoInsurance for Annual Wellness Visit

Under the Affordable Care Act, all insurance companies MUST provide an annual physical at no cost to the patient.  If you collect a copay for the annual physical, the patient will be owed a refund.

Tags: Modifiers, Preventive Services


Deadline Looms To Avoid Electronic Prescribing Penalties

June 1st, 2012

It's that time again. With a few exceptions, if you have not submitted sufficient electronic prescriptions by the end of June, you will face a 1% reduction in Medicare payments for 2012.  If you DO submit, you will instead be paid a 1% bonus on the physician service part of your Medicare reimbursements.  Typically the bonus is paid in the fall of the following year.

Details may be found at:  In brief, 25 eRxes are required for 2012 in order to qualify for full Medicare payment in 2013.  Only traditional Medicare prescriptions accompanied by a non hospital evaluation and management service qualify for the bonus.

The deadline for measurement is June 30.

There are several free qualifying electronic eRx programs.  If you would like to use Practice Fusion, you can signup through our link at  You will need to fax a form with copies of your DEA, etc.  Instructions are available on the website.  (Call John in our office if you need help.)

(KLA is a consultant for Practice Fusion.  Although this is our link for signup, we will not contact you directly.  If you wish our assistance, please call or email us.) 

Submitting the prescriptions electronically is not enough.  You must also include proccedure code G8553 on your claim form with a NON HOSPITAL BASED evaluation and management code.  If you do not "bill" for G8553 with a non-hospital based evaluation and management service, you will not get credit.

Tags: Electronic Prescribing


Small Business Bandits

May 25th, 2012

Of course, no one we know would face the problem of employee theft!

But it is a unpleasant reality we run across all too often in medical practices. 

Many medical practices are the epitome of a small business where one administrative person handles virtually everything!  Just imagine how tempting this is for even the most honest employee.

To help minimize temptation, and ensure that dollars end up where they ultimately should be, implement a system of internal controls.

An excellent article on this may be found at:

Tags: Internal Controls


Keeping Up With the Jones - OIG Examines E&M Trends

May 18th, 2012

The Officer of Inspector General recently published a report entitled "Coding Trends of Medicare Evaluation and Managment Services."

Yes, it's great reading for the insomniac; and perfect to put on the table at a sleep lab.

But it's also full of insights that will help you!

For example, every specialities' bell curve has shifted to the right between 2001 and 2010 in all visit types..  That means, providers are charging higher levels of service than they did in 2001.

Per the OIG report: "E/M services have been vulnerable to fraud and abuse."  On page 9 of the report, which may be found at, a graph shows that office established office visits 99211 through 99213 all declined in percentage of frequency.  99214 and 99215 both increased.  99214 increased an astounding fifteen percent. (15%).

Similar trends are apparent in other types of E/M service billing.

As a result of this study, OIG turned the names of 1,700 physicians over to CMS and suggested review.

Bottom line:  when keeping up with other providers' billing patterns, be sure that you have both the medical necessity and the medical documentation to support your coding. 

Tags: OIG, Evaluation and Management


Medicare's Home Health Certification in a Nutshell

May 11th, 2012

When KLA does consulting with new providers, one of the areas of missed reimbursement we find MOST FREQUENTLY is provider oversight of home health services.

Providers may bill for home health certification and recertification when certain requirements have been met.

Medicare has recently released MLN Matters SE1219 at:  which itemizing in detail what is expected when a provider certifies a patient for home health.

Of particular interest is the recap on documentation requirements.  Specifically:

Face-to-Face Documentation Requirements:

  • Documentation must be clearly titled, dated, and signed by the certifying physician, whether as part of the certification form itself, or as an addendum. It must also include the date the face-to-face encounter was performed.
  • Documentation includes a brief narrative which describes how the patient’s clinical condition, as seen during that encounter, supports the patient’s homebound status and need for skilled services.
  • The face-to-face documentation must be that of the certifying physician, and cannot be altered/changed in any way by the home health agency.
  • The face-to-face documentation is part of the certification, and the certification is required at the time the home health agency bills Medicare.
  • The face-to-face documentation can include, or exist as, checkboxes so long as it comes from the certifying physician.
  • If the physician who cared for the patient in the acute or post-acute facility chooses to use documentation that is compiled from the patient’s medical record (e.g. a discharge summary) to inform the certifying physician of how the clinical findings of the face-to-face encounter support Medicare home health eligibility for that patient, the compiled documentation must be reflective of the clinical findings of that face-to-face encounter as observed by that physician caring for the patient in the acute or post-acute facility, thus serving as that physician’s communication to the certifying physician. Further, if the certifying physician chooses to use the encounter documentation from the informing physician as his or her documentation of the face-to-face encounter, the certifying physician must sign and date the documentation, demonstrating that the certifying physician received that information from the physician who performed the face-to-face encounter, and that the certifying physician is using that discharge summary or documentation as his or her documentation of the face-to-face encounter.One physician signature, from the certifying physician, suffices if the face-to-face encounter documentation is co-located with the physician’s certification of eligibility. Otherwise, if the face-to-face documentation is attached as an addendum to the certification (a separate document), the face-to-face documentation and certification each require a signature from the certifying physician.
  • Electronic signatures are acceptable.

The article also details who can perform the face-to-face encounter.

Tags: Home Health Care


Sleep & Sports Medicine Get New Codes - Specialty Codes That Is

May 4th, 2012

Does your practice include sleep or sports medicine?

If so, time to update your 855s with Medicare.

Effective April 2, 2012, Medicare will be implementing two new speciality codes:

  • Sleep Medicine:   C0
  • Sports Medicine:  23

Rejections should start as early as October 2, 2012 IF the provider is not recognized as having the specialty code.

For more information, visit:

Tags: Sleep Medicine, Sports Medicine


CMS Issues Date of Death Occurrence Code

April 30th, 2012

Government benefits being paid to deceased beneficiaries is a growing problem in the U.S.

The National Uniform Billing Committee has created a new "occurrence" code to help capture deaths on the billing document.

Beginning October 1, 2012, occurrence code "55" must be included when patient discharge status code 20 (expired), 40 (expired at home), 41 (expired in a medical facility), or 42 (expired – place unknown) is present on the claim form.  Failure to include the code will result in a rejection of the claim.

Tags: Date of Death


Complete Signing Your Medicare Enrollment Application Electronically

April 27th, 2012

The April 24 CMS e-news had some good news.  An authorized official may now sign you enrollment application electronically:

Internet-based PECOS (Provider Enrollment, Chain, and Ownership System) now allows providers to sign Medicare enrollment applications electronically. You can save time and expedite review of your application by utilizing the electronic signature process. This feature does not change who is required to sign the application.  Authorized officials of the Organization will receive an email providing the steps they need to take to electronically sign the enrollment application. This email will be automatically sent when the enrollment application is submitted.

Make sure to add “customerservice-donotreply [at] cms.hhs [dot] gov" to your safe sender list and check your spam or junk mail folders to ensure you receive the electronic signature email notifications.

An example of the beginning of the email to the authorized official is shown below:

From: customerservice-donotreply [at] cms.hhs [dot] gov
Subject: Pending Medicare E-Signature Request ( Tracking ID: XXXXXX0047)
An application on behalf of Lexa Hospital was recently submitted by:
Submitters Name: Lexa Smith
Submitters Phone: 5555555555
Submitters Email: lexa.smith [at] lexahospital [dot] com

For more information about signing your Medicare enrollment electronically, see “Sign Your Medicare Enrollment Application Electronically” in the March 29 edition of the e-News .



Don't "Slip and Fall" Off of Medicare Rolls

April 16th, 2012

With all the paper that flows through your office, it would be easy to overlook a letter from CMS asking you to revalidate your Medicare enrollment.  Failure to do so could result in you falling off the program.

Remember how difficult it was to get enrolled the first time?

Just to be sure, you may wish to check the lists of providers sent notices to revalidate their Medicare enrollment by scrolling to the "Downloads" section at on the Centers for Medicare & Medicaid Services (CMS) website.

That site currently contains links to lists of providers sent notices from September 2011, through January 2012. Information on revalidation letters sent in February will be posted in late March.

For ease of reference, the lists are in order by National Provider Identifier and the date the notice was sent.

Tags: Revalidation


Ah-Choo! Coding for Allergy Injections

March 21st, 2012

If a patient presents at your office for an allergy injection, don't forget to capture all billable charges.

Per CPT 2012, Allergy Immunotherapy Codes 95115 through 95117 "include the professional services necessary for allergen immunotherapy.  Office visit codes may be used in addition to allergen immunotherapy if other identifiable services are provided at that time."

In addition to code 95115 (Professional services for allergen immunotherapy not including provision of allergenic extracts; single injection) or 95117 (… two or more injections), remember to include the code for the vaccine if provided by you. 

In appropriate cases, you may also bill for an office visit.

An example from Family Practice Coding Alert:

An FP sees a patient due to nasal congestion (478.19), and then the patient receives her scheduled bimonthly series of two allergy injections for allergic rhinitis due to pollen (477.0). The physician performs and documents a level-two E/M service. You may report 99212 and 95117, according to Medicare rules.

According to the Correct Coding Initiative, a modifier is not needed to code both codes.

In appropriate cases, you may even bill 99211, other staff services, with an allergy injection.  Just be sure the reason for the evaluation and management services is well documented.  Examples could include:

  • The patient was running a fever; and the staff member queried about other symptoms.
  • The patient complained about dermatitis or soreness after the least injection; and the staff member shared known reactions to the injection.
  • The patient had not been following the set schedule for injetions; and the staff member investigated why.

Although modifiers have not been required according to CCI edits since 2008, some private insurance companies do not follow standard edits.  In those cases you may need to append modifier 25 to the evaluation and management code.

In all cases, be sure to use accurate diagnosis linking.

Tags: Allergy Injections


You Say MSN, I Say EOMB

March 15th, 2012

Do you remember when an explanation of the benefits provided to a patient covered by Medicare was called an Explanation of Medicare Benefits (EOMB)? 

I do.  In fact, I completely missed the name change to Medicare Summary Notice (MSN). 

Medicare announced today that it has again redesigned the statement sent to beneficiaries as part of a new initiative – “Your Medicare Information: Clearer, Simpler, At Your Fingertips”. 

The new MSN will be available to beneficiaries this week at, Medicare's secure website for beneficiaries.  In 2013, the paper version of the form will be mailed to beneficiaries quarterly. 

Per Medicare:  "This MSN redesign reflects more than 18 months of research and feedback from beneficiaries to provide enhanced customer service and respond to suggestions and input."

You may see  a side-by-side comparison of the former and redesigned MSNs at

Tags: EOMB, Medicare Summary Notice


So You Thought HIPAA Wasn't Such a Big Deal?!?

March 14th, 2012

Thanks to Attorney Erin Brisbay McMahon, a partner with the law firm of Wyatt, Tarrant & Combs with offices in Memphis, for sharing the information below:

Some of you may remember that several years ago, BCBS of Tennessee suffered a theft of hard drives with PHI on them from a mall in Tennessee.  That was on a Friday night; an alarm went off at BCBS alerting that something was wrong at the mall but it was considered a low-risk alarm so no one checked on it until the Monday following.  Despite BCBS notifying patients and providing credit monitoring and hiring Kroll Solutions to beef up security (which itself cost millions), it settled potential HIPAA violations with HHS for $1.5 million.    

News Release

March 13, 2012

Contact: HHS Press Office
(202) 690-6343

HHS settles HIPAA case with BCBST for $1.5 million

First enforcement action resulting from HITECH Breach Notification Rule

Blue Cross Blue Shield of Tennessee (BCBST) has agreed to pay the U.S. Department of Health and Human Services (HHS) $1,500,000 to settle potential violations of the Health Insurance Portability and Accountability Act of 1996 (HIPAA) Privacy and Security Rules, Leon Rodriguez, Director of the HHS Office for Civil Rights (OCR), announced today.  BCBST has also agreed to a corrective action plan to address gaps in its HIPAA compliance program.  The enforcement action is the first resulting from a breach report required by the Health Information Technology for Economic and Clinical Health (HITECH) Act Breach Notification Rule.

The investigation followed a notice submitted by BCBST to HHS reporting that 57 unencrypted computer hard drives were stolen from a leased facility in Tennessee.  The drives contained the protected health information (PHI) of over 1 million individuals, including member names, social security numbers, diagnosis codes, dates of birth, and health plan identification numbers. OCR’s investigation indicated BCBST failed to implement appropriate administrative safeguards to adequately protect information remaining at the leased facility by not performing the required security evaluation in response to operational changes. In addition, the investigation showed a failure to implement appropriate physical safeguards by not having adequate facility access controls; both of these safeguards are required by the HIPAA Security Rule.

“This settlement sends an important message that OCR expects health plans and health care providers to have in place a carefully designed, delivered, and monitored HIPAA compliance program,” said OCR Director Leon Rodriguez. “The HITECH Breach Notification Rule is an important enforcement tool and OCR will continue to vigorously protect patients’ right to private and secure health information.”

In addition to the $1,500,000 settlement, the agreement requires BCBST to review, revise, and maintain its Privacy and Security policies and procedures, to conduct regular and robust trainings for all BCBST employees covering employee responsibilities under HIPAA, and to perform monitor reviews to ensure BCBST compliance with the corrective action plan.

HHS Office for Civil Rights enforces the HIPAA Privacy and Security Rules. The HIPAA Privacy Rule gives individuals rights over their protected health information and sets rules and limits on who can look at and receive that health information. The HIPAA Security Rule protects health information in electronic form by requiring entities covered by HIPAA to use physical, technical, and administrative safeguards to ensure that electronic protected health information remains private and secure.

The HITECH Breach Notification Rule requires covered entities to report an impermissible use or disclosure of protected health information, or a “breach,” of 500 individuals or more to HHS and the media.  Smaller breaches affecting less than 500 individuals must be reported to the secretary on an annual basis.

Individuals who believe that a covered entity has violated their (or someone else’s) health information privacy rights or committed another violation of the HIPAA Privacy or Security Rule may file a complaint with OCR at:

The HHS Resolution Agreement can be found at

Additional information about OCR’s enforcement activities can be found at




Have You Visited the AMA Website Recently?

March 12th, 2012

The AMA has recently started an online outreach for Practice Management called the Practice Management Center.

The Center offers a variety of tools to assist providers navigate the the roadmap of today's practice.  Be sure to sign up for the free Practice Management Alerts.

An example of the resources offered is a nice pocket guide to preventive service without patient cost share.  The guide provides the CPT codes and the USPSTF Grade that insurance companies should pay under the Affordable Care Act.

The site also has a Take Action section that offers tools such as a tool to help you file a complaint against an insurance company.

Tags: Preventive Services


Sexually Transmitted Infections and High Intensity Behavioral Counseling to Prevent STIs are now Preventive Services

March 7th, 2012

Medicare, Medicaid and most private insurors are now required to pay for screening for STIs and High Intensity Behavioral Counseling (HIBC) to prevent STIs. The tests are not subject to coinsurance or deductibles.

The tests must be ordered by a primary care provider; and the HIBC must be provided in primary care settings including family practice, internal medicine and ob-gyn offices.  Hospital based care including emergency departments are not considered primary care settings for these services.

STIs included are Chlamydia (86631, 86632, 87110, 87270, 87320, 87490, 87491, 87810, 87800 (used for combined Chlamydia and gonorrhea testing), gonorrhea (87590, 87591, 87850, 87800 (used for combined Chlamydia and gonorrhea testing), syphilis (86592, 86593, 86780), and hepatitis B (hepatitis B surface antigen) 87340, 87341)). 

Codes V74.5 or V73.89 and V69.8, denoting STI screening and high-risk behavior, respectively, and/or V22.0, V22.1, or V23.9, denoting pregnancy as appropriate must be included for the tests to be treated as preventive.

Bill new code G0445 (high-intensity behavioral counseling to prevent sexually transmitted infections, face-to-face, individual, includes: education, skills training, and guidance on how to change sexual behavior)  for HIBC.  CMS will cover semi-annual sessions, twenty to thirty minutes in length, per year.  The code pays approximately $24 depending on your jurisdiction.

The visit must be linked to the correct diagnosis code.  Per CMS in MLN Matters® Number: MM7610:

  • The appropriate screening diagnosis code (ICD-9-CM V74.5 (screening bacterial – sexually transmitted) or V73.89 (screening, disease or disorder, viral, specified type NEC)), when used with the screening lab tests identified by Change Request (CR) 7610, will indicate that the test is a screening test covered by Medicare.
  • Diagnosis code V69.8 (other problems related to life style) is used to indicate that the beneficiary is at high/increased risk for STIs. Providers should also use V69.8 for sexually active adolescents when billing G0445 counseling services.
  • Diagnosis codes V22.0 (supervision of normal first pregnancy), V22.1 (supervision of other normal pregnancy), or V23.9 (supervision of unspecified high-risk pregnancy) are also to be used when appropriate.

This code may be paid on the same date of service as an annual wellness visit (AWV), evaluation and management (E&M) code, or during the global billing period for obstetrical care..

An E&M code should not be billed when the sole reason for the visit is HIBC to prevent STIs. If there is a different diagnosis, however, both may be billed on the same day.

Please review MLN Matters® Number: MM7610 for details on documentation requirements.

Tags: Preventive Services, STIs


ERx - The Carrot and the Stick

March 2nd, 2012

A few of our clients received letters yesterday from CMS saying their reimbursement would be decreased by 1% because they had not complied with Medicare ERx guidelines.  The letters also said that Medicare had not yet processed the requests for hardship exemptions that were due at the end of October, 2011.

Fortunately, Medicare has modified its rules for 2012 making it a little easier for providers to comply with ERx requirements and avoid 2013's 1.5% decrease for noncompliance.

Now, a provider can submit an ERx with ANY visit; not just with certain outpatient 90000 level codes.  Thus, you may wish to include G8553 with charges for hospital claims where prescribing is done electronically.  Hospital codes were not acceptable in 2012 for ERx compliance purposes.

Note, however, that using this option only avoids penalties; it does not satisfy requirements for ERx incentives.  In order to receive the individual provider 2012 incentive payments, providers still must report ERxs primarily with office evaluation and management services. 

To be a successful electronic prescriber for the 2012 eRx Incentive Program and earn a 1.0% incentive payment for the 2012, a provider must report the eRx measure for at least 25 unique electronic prescribing events during 2012.  The measuring, however, is January 1 through June 30 so best practices would require 25 accepted claims before June 30 per practitioner.

To know if your ERx has been accepted by the National Claims History database, look for denial code N365 on your remittance advice.  (KLA tracks these for our billing clients.)  Yes, it is counter-intuitive to look for a denial code; but remember you are charging out 0 for this code.  Thus, Medicare is paying nothing on the EOB.

Medicare issued a summary of the 2012 requirements in January 2012.  The link is a good summary, but unfortunatly many of the links within the document aren't active.  The correct link to the CMS section about ERx is:

A group practice may also potentially qualify to earn an eRx incentive payment equal to 1.0% of the group practice's   total estimated Medicare Part B Physician Fee Schedule (PFS) allowed charges for covered professional services furnished during the 2012.  Small groups must complete 625 ERxs to qualify.  Large groups must complete 2,500.

To qualify for the group incentive you must self nominate for 2012.  Nomination forms are available on the CMS ERx Incentive pages under Group Practice Reporting.

If you need a free method for ERx, feel free to sign up for Practice Fusion through KLA's link at:  KLA will not contact you if you take advantage of our link; but feel free to call us with questions.

You will need to fax Practice Fusion some information such as your DEA and proof of identity to get set up for ERx, but it is a free service.  In fact, Practice Fusion had the more providers qualify for stimulus money in 2012 than any other EMR system.

Tags: ERx, Incentives


Medicare, Secondary Insurance and Coordination of Benefits

March 1st, 2012

Medicare, Secondary Insurance and Coordination of Benefit problems may not be at the very top of our list of reimbursements issue, but it's very close.

  • We see it when Medicare denies because it's not the primary payor,
  • We see it when we get a denial from a secondary insurance company that the patient doesn't have, and
  • We see it when, despite our providing all information via the new nightmarish 5010 standards, Medicare doesn't appropriately "crossover" to secondaries requiring arduous paper filing with Medicare eobs or online submission through the carrier with scanned attachments. 

 No wonder so many offices just give up on secondary dollars!

Medicare relies on the secondary insurance company to self report a new enrollee.  If the secondary company does not, what can a provider do?

The brief answer is, provide proof of the patient's secondary insurance to the COBC (Coordination of Benefits Contractor).

Telephone:  1-800-999-1118 (8 AM to 8 PM Eastern Time)

Fax:  1-734-957-9598 (address the fax to Medicare Coordination of Benefits)

Mailing address:  Medicare –Coordination of Benefits, P.O. Box 33847, Detroit, MI 48232

Because of the number of conflicts in the information CMC and COBC receives, CMS revised its data management "reporting hierarchy" process on December 7.  The official document may be found at:

Here are the highlights:

ONE TIME ONLY, a provider office may call the COBC when the patient is in the office and correct the information over the phone.  After that, all proof must be sent by mail or fax.

To speed up your reimbursement process, train your front desk staff to always check secondary insurance.  If there has been a change, be sure to retain proof of the secondary insurance such as an enlarged, legible copy of the secondary insurance card.

If you have an historical problem with a patient's secondary insurance, call the COBC while the patient is in the office and near the phone to attempt the ONE TIME ONLY option to correct over the phone.

Tags: Secondary Insurance, Coordination of Benefits


CMS Issues Proposed Requirements for Stage 2 EHR

February 29th, 2012

On February 24, CMS released a Fact Sheet about its proposal for the Stage 2 meaningful use requirements of electronic health records (EHRs).

The new proposed rule primarily expands on Stage 1 requirements. For example, Providers will be required to report on 12 clinical quality measures (CQMs) in Stage 2.  They were required to report on 6 in Stage 1.  Other changes include making reporting which was optional in Stage 1, mandatory in Stage 2. 

Per the Fact Sheet, proposed changes include:

  • Changes to the denominator of computerized provider order entry (CPOE) (Stage 1 Optional, Stage 2 Required)
  • Changes to the age limitations for vital signs (Stage 1 Optional, Stage 2 Required)
  • Elimination of the “exchange of key clinical information” core objective from Stage 1 in favor of a “transitions of care” core objective that requires electronic exchange of summary of care documents in Stage 2 (Effective Stage 2)
  • Replacing “provide patients with an electronic copy of their health information” objective with a “view online, download and transmit” core objective. (Effective Stage 2)

Specialists will be impacted more than primary care providers in Stage 2. Per the Fact Sheet meaningful use will require:

  • Imaging results and information accessible through certified EHR technology
  • Capability to identify and report cancer cases to a State cancer registry, except where prohibited, and in accordance with applicable law and practice
  • Capability to identify and report specific cases to a specialized registry (other than a cancer registry), except where prohibited, and in accordance with applicable law and practice.

The proposed rule seeks to extend Stage 1 so that providers would have until 2014 to implement Stage 2.  Per the Fact Sheet, the delay "would allow the needed time for vendors to develop Certified EHR Technology that can meet the Stage 2 requirements."




Tags: EHR


AMA Issues CPT Errata for 2012

February 27th, 2012's impossible to be perfect!

Despite the AMA's best efforts, 2012 CPT did have far 12 pages of them!

The errata may be found at:

The page also offers a link to sign up for notifications about future errata.

Tags: CPT, Errata


Place of Service for Distant Site

February 13th, 2012

It's not always easy to know where services to a patient are rendered where the physician component of a diagnostic procedure is done at a site distant from the technical component.

CMS has clarified how to treat these types of claims in MLN Matters Number:  MM7631.

The short answer is:  the place of service is where the patient received face-to-face service.

The example given in the Medlearn article is: 

A beneficiary receives an MRI at an outpatient hospital near his/her home. The hospital submits a claim that would correspond to the TC portion of the MRI. The physician furnishes the PC portion of the beneficiary’s MRI from his/her office location – POS code 22 will be used on the physician’s claim for the PC to indicate that the beneficiary received the face-to-face portion of the MRI, the TC, at the outpatient hospital.

There are just two exceptions to this rule that deal with a patients admission status in a hospital.  If the patient is classified as inpatient but goes to an outpatient part of the facility to receive a test, the place of service would remain inpatient.


Tags: Place of Service


Compliance Tools for Beginners

February 6th, 2012

Failing to be "in compliance" is costing many providers' offices tens to hundreds of thousands of dollars.  Regardless of how you feel about the politics of the overhead burden on providers, the penalties are real.

There are some tools available to help you.  For example, visit CMS's archive of Quarterly Compliance Newsletters.  This will help you key in to the primary areas of concern.

Or visit, CMS's Compliance page.  It offers "Fast Facts" to help with compliance.

Overwhelmed with all the compliance material?  Just plain tired of reading? 

The OIG has made it a little easier for the TV/YouTube/IPad generations by addressing some of the more complicated compliance issues with podcasts.

The program began in December 2011 and the list of podcasts keeps growing. Some of our favorites include:  Compliance Program Basics, Tips for Implementing an Effective Compliance Program and Importance of Documentation.

Don't forget the popcorn!

Tags: Documentation, Compliance Plan


2012 Welcomes New Waived Labs

January 27th, 2012

CMS updated it's list of waived laboratories on January 24.  The entire list may be found at:

Be sure to check with insurance carriers about coverage requirements.  Just because you can perform a test in an office; does not mean you will be reimbursed for it.

Many of the new waived labs are associated with drug screening.  There are state and federal laws associated with doing work-related drug screeing INCLUDING confirmatory screenings with a second method and allowing explanations as to why a test might be positive.  Be sure to check with an authority before performing these tests. 

Tags: Waived Labs


Affordable Care Act & Preventive Services

January 9th, 2012

The first of the year is the time most providers are challenged by huge first of the year expenses and slow downs in cash flow because of deductibles.

As mentioned before, it's the perfect time to focus on preventive services.  The Affordable Care Act requires that most NEW private insurance policies offer certain preventive services to patients without any cost share.

Cigna has published a very good Guide to Preventive Services that can be used as a blue print for most private insurance plans.  Each company has slight nuances, but this is a very good place to start.

Tags: Preventive Services, Modifier 33, Cigna

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Alcohol Misuse Screening and Counseling Now Covered by Medicare In Primary Care Setting

December 5th, 2011

Effective October 14, 2011, Medicare is covering two new G codes, G0442 (Annual Alcohol Misuse Screening, 15 minutes), and G0443 (Brief face-to-face behavioral counseling for Alcohol Misuse, 15 minutes) are available for primary care providers.  Payment for the service is approximately $16 for the screening and $24 for the 15 minutes behavioural counseling.  As with most preventive services,deductibles and coinsurance do not apply.

Medicare uses a definition of alcohol misuse which includes risky/hazardous and harmful drinking which place individuals at risk for future problems.

In the general adult population, risky or hazardous drinking is defined as >7 drinks per week or >3 drinks per occasion for women, and >14 drinks per week or >4 drinks per occasion for men. Harmful drinking describes those persons currently experiencing physical, social or psychological harm from alcohol use, but who do not meet criteria for dependence.

Per MLN Matters Number MM7633:

Effective for claims with dates of service October 14, 2011, and later, CMS shall cover annual alcohol screening, and for those that screen positive, up to four, brief, face-to-face behavioral counseling interventions per year for Medicare beneficiaries, including pregnant women:

  1. who misuse alcohol, but whose levels or patterns of alcohol consumption do not meet criteria for alcohol dependence (defined as at least three of the following: tolerance, withdrawal symptoms, impaired control, preoccupation with acquisition and/or use, persistent desire or unsuccessful efforts to quit, sustains social, occupational, or recreational disability, use continues despite adverse consequences); and,
  2. who are competent and alert at the time that counseling is provided; and,
  3. whose counseling is furnished by qualified primary care physicians or other primary care practitioners in a primary care setting.

Each of the four behavioral counseling interventions must be consistent with the 5As approach that has been adopted by the USPSTF to describe such services:

  1. Assess:  Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
  2. Advise:  Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
  3. Agree:  Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
  4. Assist:  Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
  5. Arrange:  Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

For the purposes of this covered service, the following provider specialty types may submit claims for G0442 and G0443:

  1. 01-General Practice
  2. 08-Family Practice
  3. 11-Internal Medicine
  4. 16-Obstetrics/Gynecology
  5. 37-Pediatric Medicine
  6. 38-Geriatric Medicine
  7. 42-Certified Nurse Midwife
  8. 50-Nurse Practitioner
  9. 89-Certified Clinical Nurse Specialist
  10. 97-Physician Assistant

For purposes of this covered service, the following place of service (POS) codes are applicable:

  1. 11-Physician’s Office
  2. 22-Outpatient Hospital
  3. 49-Independent Clinic
  4. 71-State or local public health clinic


Tags: Alcohol Misuse, Preventive Services


Medicare To Pay for Behavioral Therapy for Obesity

December 5th, 2011

Medicare will now pay for Intensive Behavioral Therapy for patients with obesity.

According to Medicare, obesity is defined as a BMI of 30 kg/m2.  This counseling is not subject to deductibles nor coinsurance.

Medicare will pay for:

  • One face-to-face visit every week for the first month;
  • One face-to-face visit every other week for months 2-6; and
  • One face-to-face visit every month for months 7-12, if the beneficiary meets the 3kg (6.6 lbs) weight loss requirement during the first 6 months.

According to MLN Matters MM7641:

Effective for claims with dates of service on or after November 29, 2011, Medicare will recognize HCPCS code G0447, Face-to-Face Behavioral Counseling for Obesity, 15 minutes.

G0447 must be billed along with 1 of the ICD-9 codes for BMI 30.0 and over (V85.30-V85.39, V85.41-V85.45).

IBT for obesity consists of the following:

  1. Screening for obesity in adults using measurement of BMI calculated by dividing weight in kilograms by the square of height in meters (expressed kg/m2)
  2. Dietary (nutritional) assessment; and,
  3. Intensive behavioral counseling and behavioral therapy to promote sustained weight loss through high intensity interventions on diet and exercise.

Intensive behavioral intervention for obesity should be consistent with the 5-A framework:

  1. Assess: Ask about/assess behavioral health risk(s) and factors affecting choice of behavior change goals/methods.
  2. Advise: Give clear, specific, and personalized behavior change advice, including information about personal health harms and benefits.
  3. Agree: Collaboratively select appropriate treatment goals and methods based on the patient’s interest in and willingness to change the behavior.
  4. Assist: Using behavior change techniques (self-help and/or counseling), aid the patient in achieving agreed-upon goals by acquiring the skills, confidence, and social/environmental supports for behavior change, supplemented with adjunctive medical treatments when appropriate.
  5. Arrange: Schedule follow-up contacts (in person or by telephone) to provide ongoing assistance/support and to adjust the treatment plan as needed, including referral to more intensive or specialized treatment.

This service will only be paid to the following specialty types:

01 - General Practice

08 - Family Practice

11 - Internal Medicine

16 - Obstetrics/Gynecology

37 - Pediatric Medicine

38 - Geriatric Medicine

50 - Nurse Practitioner

89 - Certified Clinical Nurse Specialist

97 - Physician Assistant

Services, however, may be rendered by appropriate auxilliary personnel.

Payment for the 15 minute IBT session will be $22 to $25 dollars depending on jurisdiction and place of service.



Tags: Obesity, Preventive Services, IBT


Modifier 33?

November 14th, 2011

Having problems being paid for preventive testing?  Medicare anticipated such problems when it added modifier 33 as a HCPCS II code to be effective January 1, 2011.

Modifier 33 should be used in addition to an allowed preventive diagnosis on procedures that are not preventive BY DEFINITION.  Thus, you would add a modifier 33 for Cardiovascular Screening Tests; but not to an annual wellness exam.

Although it excludes some of the newly added preventive services, an excellent resource is Medicare's Quick Reference Card to Preventive Services

Using Cardiovascular Screening Tests as an example, you would code:

Lipid Panel as 80061-33

Cholesterol as 82465-33

Lipoprotein as 83718-33, and 

Triglycerides as 84478-33.

The diagnoses would be one or more of the following codes:  V81.0, V81.1, V81.2.

Note that this will be paid as preventive only once every five years; so keep good records.

Follow these guidelines and you WILL get these items paid without your patient being responsible for any copay or deductible.


Tags: Preventive Services, Modifiers


OIG Healthcare Targets for 2012

October 10th, 2011

On October 5, the Office of Inspector General released it's 2012 work plan. 

Medicare Part B areas that will be investigated include:

  • Incident to services--specifically for those that physicians that collect more than the norm for their speciality.
  • Unrelated services provided during global surgery periods.
  • Place of service errors.
  • Compliance with assignment rules--specifically are providers writing-down or writing-off per Medicare determinations.
  • Ambulatory service centers.
  • Chiropractors.
  • Sleep testing.
  • Excessive payments for diagnostic radiology.

For the complete plan for Medicare Part B, visit

Tags: OIG, Incident To


Reminder: It's Against the Law to Bill Medicare QMB Patients

October 3rd, 2011

Dollars are tight.  Many Medicaid programs are putting limitations on the number of visits they will pay in a year.

Confusion reigns as to whether or not you can balance bill a Medicaid patient who has exceeded the number of visits in a year.  The short answer is probably no, but check with your Medicaid carrier to be sure.

One thing is for certain though:  It is against federal law to balance bill a Medicare QMB patient, ie a patient with Medicare primary and Medicaid secondary.

This has become such an issue that CMS has published a reminder at:

Tags: Medicaid, QMB


Baffled by Preventive Services?

July 11th, 2011

Are you confused by the new Preventive Services offered by Medicare?

The Medicare Learning Network has recently updated several of their brochures to include changes from the Affordable Car Act.

Per CMS's press release, the following resources are now available:

“Quick Reference Information: Preventive Services” offers coverage, coding, and payment information on the wide variety of preventive services Medicare covers.  View, download, or print at

“Quick Reference Information: The ABCS of Providing the Initial Preventive Physical Examination (IPPE)” offers a list of the elements included in the IPPE, along with some frequently asked questions.  View, download, or print at

“Quick Reference Information: The ABCs of Providing the Annual Wellness Visit (AWV)” offers a list of the elements included in the AWV, along with some frequently asked questions.  View, download, or print at

“Quick Reference Information: Medicare Immunization Billing” offers coverage, coding, and payment information for the seasonal influenza, pneumococcal, and hepatitis B vaccines.  View, download, or print at

The MLN® also offers these charts in a laminated, ring-bound booklet titled “Quick Reference Information Resources: Medicare Preventive Services.”  This booklet contains all four of the preventive services charts listed above in a single, easy-to-use format.  To order your free copy, visit the Preventive Services MLN page at, then scroll to “MLN Product Ordering Page” in the “Related Links Inside CMS” section.

Tags: Preventive Services


Your Future and ACOs

March 31st, 2011

The proposed ACO guidelines were issued today.  They remain extremely vague not even defining who will be in charge of administering the health care dollar in ACOs. The guidelines do say that payments will continue under a fee for service paradigm.  However, there will be bonuses issued to providers for improving quality and decreasing cost. 

In a related story, the Federal Trade Commission has issued a statement saying that EVERY ACO will fall under FTC scrutiny for antitrust violations.   The FTC does say it is committed to assist in anything that will help lower the cost of healthcare; but also refers to the number of studies that show that ACOs will drive the cost of healthcare up not down.  

A very good article may be found at:

The HHS statement may be found at:

Tags: Accountable Care Organizations


CMS's New Waived Labs

March 2nd, 2011

Change request 7266 from Medicare adds some new waived labs and changes the codes on others.  To view the change request, visit:

If you scroll down to page 7 of the document, you will find a complete list of waived tests.

The new tests are:  

  • BTNX, Inc. Strep A Rapid Test
  • Consult Diagnostics Mononucleosis Cassette {Whole Blood}
  • BTNX Inc. Rapid Response Fecal Immunochemical Test (FIT)
  • American IVD Biotechnology Services Inc. FOB/CRC Advanced+
  • Amedica Biotech AmediCheck Instant Test Cup
  • Confirm Biosciences Drugconfirm instant multi-drug test kit, Multi-Drug of Abuse Urine Test
  • Insight Medical Multi-Drug of Abuse Urine Test
  • Jant Pharmacal Corporation Accutest Drug Test Cup
  • Micro Distributing II, Ltd Multi-Drug of Abuse Urine Test
  • Millennium Laboratories Multi-Drug of Abuse Urine Test
  • NexScreen LLC, NexScreen Cup
  • On the Spot Drug Testing Multi-Drug of Abuse Urine Test
  • Physicians’ Test Multi-Drug of Abuse Urine Test
  • Total Diagnostic Solutions Multi-Drug of Abuse Urine Test
  • UCP Biosciences, Inc. Drug Screening Test Cards
  • UCP Biosciences, Inc. Multiple Drug Screen Cups

Codes and implementation dates are available at the link above.

In addition, the change request changes the code from the popular G0431 code, "Drug screen, qualitative; single drug class method (e.g., immunoassay, enzyme assay), each drug class"  TO G0434QW "Drug screen, qualitative; multiple drug classes by high complexity test method (e.g., immunoassay, enzyme assay), per patient encounter."

This change was necessary to align Medicare with the changes in 2011 CPT. The screens impacted are:

  • Phamatech QuickScreen One Step Amphetamine Test,
  • Accu-Stat Drugs of Abuse Home Test for Marijuana (THC),
  • ADC CLIA Waived Marijuana (THC) Test,
  • First Check Diagnostics LLC, First Check Home Drug Test Marijuana,
  • Phamatech QuickScreen One Step THC Screening Test,
  • Phamatech At Home Drug Test (Model 9078),
  • Phamatech At Home Drug Test (Model 9078T),
  • Worldwide Medical Corporation, First Check Home Drug Test (THC),
  • Phamatech At Home Drug Test (Model 9073),
  • Phamatech At Home Drug Test (Model 9073T),
  • Phamatech QuickScreen One Step Cocaine Screening Test,
  • Phamatech At Home Drug Test (Model 9068),
  • Phamatech QuickScreen One Step Methamphetamine Test,
  • DyanGen NicCheck II Test Strips,
  • Mossman Associates, Inc. NicCheck I Test Strips,
  • Phamatech At Home Drug Test (Model 9083),
  • Phamatech QuickScreen One Step Opiate Screening Test, and
  • Phamatech At Home Drug Test (Model 9133).
Tags: Waived Labs


Do You Feel Bullied?

March 1st, 2011

Ok, this might not be the best medical office management topic.

Still, many of us who love kids have run into the dilemma of what to do about bullying.  Sometimes, as adults we may face the same dilemma in the workplace.

HHS’ Health Resources and Services Administration has a campaign called Stop Bullying Now, which offers advice to Stop Bullying Now!  See

Patients turn to their doctors for all types of help.  This may be a topic you are asked about.  Having this reference on hand would be helpful.


Tags: Resources


HHS Report on ACA and State Funding

February 25th, 2011

HHS released a new report showing that the Affordable Care Act provides states with significant flexibility and resources to improve health care benefits and protect consumers. Per HHS, the law has provided or offered $2.8 billion in funding to states and more is available to help states implement new consumer protections, expand health coverage, and improve health care quality.

“The Affordable Care Act is built on the foundation of providing states with the resources and flexibility they need to build a better, more affordable health care system,” said HHS Secretary Kathleen Sebelius. “This report shows that states have what they need to continue putting comprehensive health insurance reforms in place.”

To access the entire report, visit:

Tags: Affordable Care Act, State Funding


Avoiding the eRx 2% Swing

February 24th, 2011

Time to get on board the eRx express.  Even if you aren't fully sold on the advantages of electronic prescribing, failure to do so will cost you one percent of your Medicare dollars beginning in 2012.  If you do participate in the program, you will get a bonus instead.

For 2012, that a two percent swing in your Medicare revenue.

CMS issued the following guidance today:

2011 Electronic Prescribing (eRx) Incentive Program Reminder-Avoiding the Adjustment
In November, the Centers for Medicare & Medicaid Services announced that, beginning in calendar year 2012, eligible professionals who are not successful electronic prescribers based on claims submitted between January 1, 2011 – June 30, 2011, may be subject to a payment adjustment on their Medicare Part B Physician Fee Schedule (PFS) covered professional services. Section 132 of the Medicare Improvements for Patients and Providers Act of 2008 (MIPPA) authorizes CMS to apply this payment adjustment whether or not the eligible professional is planning to participate in the eRx Incentive Program. 
From 2012 through 2014, the payment adjustment will increase each calendar year.  In 2012, the payment adjustment for not being a successful electronic prescriber will result in an eligible professional or group practice receiving 99% of their Medicare Part B PFS amount that would otherwise apply to such services.  In 2013, an eligible professional or group practice will receive 98.5% of their Medicare Part B PFS covered professional services for not being a successful electronic prescriber in 2011 or as defined in a future regulation. In 2014, the payment adjustment  for not being a successful electronic prescriber is 2%, resulting in an eligible professional or group practice receiving 98% of their Medicare Part B PFS covered professional services.
The payment adjustment does not apply if <10% of an eligible professional’s (or group practice’s) allowed charges for the January 1, 2011 through June 30, 2011 reporting period are comprised of codes in the denominator of the 2011 eRx measure. 
Please note that earning an eRx incentive for 2011 will NOT necessarily exempt an eligible professional or group practice from the payment adjustment in 2012.
How to Avoid the 2012 eRx Payment Adjustment

Eligible professionals – An eligible professional can avoid the 2012 eRx Payment Adjustment if (s)he:    

  • Is not a physician (MD, DO, or podiatrist), nurse practitioner, or physician assistant as of Jun 30, 2011 based on primary taxonomy code in NPPES;      
  • Does not have prescribing privileges. Note: (S)he must report (G8644) at least one time on an eligible claim prior to June 30, 2011;    
  • Does not have at least 100 cases containing an encounter code in the measure denominator;     
  • Becomes a successful e-prescriber; and     
  • Reports the eRx measure for at least 10 unique eRx events for patients in the denominator of the measure. 

Group Practices- For group practices that are participating in eRx GPRO I or GPRO II during 2011, the group practice MUST become a successful e-prescriber.    

Depending on the group’s size, the group practice must report the eRx measure for 75-2,500 unique eRx events for patients in the denominator of the measure.For additional information, please visit the “Getting Started” webpage at on the CMS website for more information; or download the Medicare’s Practical Guide to the Electronic Prescribing (eRx) Incentive Program under Educational Resources.


There are several free qualifying electronic eRx programs.  If you would like to use Practice Fusion, you can signup through our link at  You will need to fax a form with copies of your DEA, etc.  Instructions are available on the website.

(KLA is a certified consultant.  Although this is our link for signup, we will not contact you directly.  If you wish our assistance, please call or email us.) 

Submitting the claims is not enough.  You must also include proccedure code G8553 on your claim form with a NON HOSPITAL BASED evaluation and management code.  For more details, unzip:

Tags: Electronic Prescribing, Bonuses,


Charting With iPad, Android

February 22nd, 2011

For those of you that are using Practice Fusion, one of the most requested features is now available.  You can now access your account from your iPhone or Android telephone/mobile device or iPad.   You can now chart anywhere you have a SECURE WiFi device. In order to do this you need your free Practice Fusion account (sign up at and the $29.95 LogMeIn Ignition app which is available in your App store.

Tags: Practice Fusion


RAC Auditors Approved Issue List

February 17th, 2011

Concerned about a visit from RAC auditors. 

You can be a little better prepared by knowing what areas they are authorized to audit.  A list of current approved issus may be found at:

Each topic includes a list of states and types of providers that may be audited by topic; as well as other resources for further research.

In addition to following the education, review and reporting guidelines in your Compliance Plan, consider:

1.  Print out the topics from the above website that apply to your practice,

2.  Review the supporitng information,

3.  Add to your compliance plan,

4.  Self audit.  Check our resources pages for a list of recommended external auditors,

5.  Include results of audit in your Compliance notebook.

Tags: RAC, Medicare Auditors, Compliance Plan


TennCare Cuts?

February 4th, 2011

Several of our Tennessee clients have expressed concerns over the TennCare cuts that may go into effect July 1.

For a summary of cuts, visit:

What concerns most of our clients is the eight day limit for hospital inpatient service, physician and nurse practitioner office visits and laboratory services. 

Although we aren't fortune tellers, we think (and hope) the cut is unlikely.

The Affordable Care Act prohibits the reduction in eligibility for Medicaid between when the bill was passed in March 2010 and when the Act will be substantially implemented in 2014.  Reducing eligibility = no federal funding.  Although the amendments do not technically go to eligibility, the spirit of the Affordable Care Act was not just elibility but any reduction in benefits.

Per KHN:  Governors are bristling against rules in the stimulus program and the health overhaul law that generally require them to maintain current Medicaid levels for adults until 2014, when much of the law kicks in, or risk losing federal matching funds. They say they need to be able to trim their Medicaid rolls now because their state budgets are in such dire straits – partly because stimulus funding that helped many prop up their health programs ends in June.

In Tennessee, cuts similar to those proposed for July were averted in 2010 when the hospitals agreed to a 3.5 percent fee on revenues.  Hospitals will likely agree to continue the fee instead of facing the potential of no pay for Medicaid patients who exceed the eight days of inpatient visits.

Since Federal law requires Advance Notice of any change in Medicaid coverage, Tennessee put the public on notice about the proposed changes in case other funding options do not materialize.

Tags: TennCare, Affordable Care Act


Templates for Medicare Wellness Visits, CANS-MCI for Cognitive Impairment

January 21st, 2011

This one is going to be a long one; but it's important to your bottom line, so please take a minute to read.

Several of our primary care clients have told us that the reporting requirements for the Medicare wellness exams are so extensive they would probably elect not to do the exams. 

To try to encourage our clients to conduct the exams, KLA has developed a Medicare Wellness Visit template (in Word format) that can be used for all your Medicare Wellness Visits from IPPE (Welcome to Medicare) to Subsequent Annual Wellness Visit.

For every primary care client for which we've run the numbers, performing the Medicare Wellness visits can mean $50,000 or more in annual income.  Some of our clients would have in excess of $100,000 in additional income based on the number of Medicare patients seen by a single physician.  PLUS, these visits are not subject to cost sharing, ie deductible or co-pays.  By scheduling them early in the year, a practice can minimize the impact of the annual Medicare deductible on its cash flow.

Today, Family Practice Management issued a good digital article on the IPPE and Annual Wellness Visit.  This article explains why, if you are a primary care provider, you NEED TO offer these services.  The article includes another template for the Medicare Prevent Physical Exam.  You may prefer it to the one KLA put together.  It includes elements that the KLA template assumes are maintained elsewhere in your patient file such as history, allergy and medication lists.

For the official word from Medicare, visit:

In the KLA template, there are two items that may need further explanation.

The first is a reference to Caring Connections under Advance Planning. We blogged about this site a few weeks ago.  In a nutshell, it's a site that offers free, downloadable, state-specific advance planning directives. 

The second is a reference to CANS-MCI under Cognitive Assessment.  I borrowed the following (with permission of course) from reimbursement Guru Don Self's recent newsletter:

"...the fourth measure of the new annual Medicare exams is “Detect any Cognitive Impairment”. The Medicare program does not dictate to you HOW you detect it, but only that you do so.

There is a simple—yet very effective—method of Cognitive testing, that requires almost no staff time to accomplish, and takes away the “guesswork” that an MMSE involves. This Cognitive Testing is testing for memory, attention, response speed & processing speed and requires an average of 25 to 40 minutes of the patient’s time in your own office. This is so much easier on the patient than sending them across town, and it is very profitable for our clients.

We (Don Self) recommend and sell the Computer-Administered Neuropsychological Screen for Mild Cognitive Impairment (CANS-MCI®). This test was developed as an instrument for detection of mild cognitive impairment, that is not only self-administered (by the patient), but also is touch screen driven to practically eliminate you or your staff having to sit with the patient while they take the test.  It is common knowledge that the earlier you detect the chronic disease process, the better chance you have of making a difference in the progression of the disease.  Neuropsychological or imaging evaluations early enough in the pre-clinical phase of the disease enhance the effectiveness of treatments.

It is possible for you to provide this service to your patients and get the point-of-care information to make medical decisions, without having a capital outlay. One tool we have added to our arsenal in helping physicians is the CANS-MCI test and it does not require any capital investment. Medicare (as well as CIGNA, UHC, BCBS and every other carrier we have reviewed) pays for the following codes when done in a physician office, which is part of the CANS-MCI test:

96103: Psychological testing admin. by computer $57.44

96120: Neuro-psych test administered with computer $89.43

The average Medicare allowed in the country are shown, so this means that Medicare’s allowed in your area will be about $146.87."

If you want to learn more about CANS-MCI, please contact Don directly at:  donself [at] donself [dot] com.

By 2015, Medicare is scheduled to transition to a patient managed rather than fee-for-service model.  By keeping up each step of the way, your practice will be ready for the transition.

Please share this information with other primary care providers.  Together, each one of us is stronger.


Are Your Informed Consent Forms Bullet Proof?

January 17th, 2011

Some patients are litigious.

It’s an unfortunate fact of a doctor’s life that they must look at every patient as a possible plaintiff in a malpractice suit.

And, juries like to compensate those with injuries whether or not the doctor has done anything wrong.

I’m often reminded of the story told by a friend who served on a jury a few years ago.  The plaintiff had stepped off a well-marked curb and fell as she was leaving a restaurant.  The elderly plaintiff broke her leg in several places and sued the restaurant.

Although the evidence was incontrovertible that the restaurant had marked the curb and provided a nearby ramp, my friend said she still was tempted to vote in favor of the plaintiff just because the restaurant “could afford to pay.”

How prepared are you if through no fault of your own a procedure has a negative outcome?

As part of your practice’s New Year’s resolutions, why not review your Informed Consent forms and accompanying handouts.  Are they comprehensive? 

Many of the specialty societies are now providing language that may be included for you procedures.  Check the handouts you give your patients about procedures to ensure they include:

  • A description of the procedure,
  • Possible risks and benefits of the procedure,
  • Alternatives to the procedure, if any,
  • Aftercare instructions including contact information should the patient need assistance,
  • Estimated cost of the procedure.

We have a rudimentary form for your use at:

This form is designed to be accompanied with handouts explaining the above.

The form also includes permission to film the procedures.


Advance Care Directives

January 12th, 2011

Part of Medicare's requirements for its new Annual Wellness Visit is the opportunity for the patient to discuss advanced care planning with a provider. 

Yes, it seems providers are now expected to be doctors and lawyers.

Thanks to, the task need not be daunting. This website has many tools to assist your patient with advanced care planning including free downloadable state specific advance directives with comprehensive instructions on how to accurately complete it.

If your patient is computer-literate, you may provide him/her with a link to the site.  If you patient needs a little help in the computer usage department, you can download the forms for the patient to complete.

The site offers many additional tools for your patient and caregivers such as brochures on how to choose an agent and on how to be an agent.

If your patient has an Advance Care Directive, please obtain a copy for the patient's file.  Alternately, the patient my choose to use a free service such a Google Health that allows the directive to be stored securely online.  Login information can be given to health care providers as needed.

In any case, a provider needs to know if there is and Advance Care Directive.  If there is, who is the patient's agent for healthcare decisions.


National Safety Goals - Medication Reconciliation

January 7th, 2011

How long has it been since you've reviewed your medication reconciliation procedures? 

Although most of us associate the Joint Commissions with the hospitals: their authority extends further.  If you do surgery in your office, you too are subject to their review. 

 Before you stop reading, believing this doesn't apply to you, consider:

  • Do you do injections?
  • Do you do lesion removals?
  • Do you sometimes sew up a cut?

Technically, all of the above are surgeries.

New medication reconciliation standards will go into effect July 1, 2011,  The draft copy of the standards as well as other safety goals related to the office surgery practice may be found at:

Even if a visit from the joint commissions to your practice is unlikely, keep in mind that standards such as these can and are used to show a reasonable standard of care in malpractice cases.




Day One for EHR Bonuses

January 3rd, 2011

Today is the first day providers may sign up for bonuses available for the meaningful use of EHR.

The final regs were published today about requirements to qualify for incentive bonsues for EHR.  The 277 page document basically says stop gap measures will continue through 2011.
The rule describes the permanent certification program for electronic health records (EHR), and how organizations become authorized to test and certify EHR technology.
ONC plans to replace the temporary program currently in effect with the permanent version January 1, 2012, but it also say it will delay the date if necessary.

To learn more about the Medicare and Medicaid bonus program, as visit the CMS website at:

To determine if you are eligible for either the Medicare or Medicaid EHR incentive programs visit:



Changes for ESRD Capitation for 2011

December 30th, 2010

If your receive Medicare Monthly Capitation Payments (MCPs) to manage ESRD patients remember these requirements for ESRD beneficiaries to access ESRD-related drugs that go into effect January 1, 2011. It's important to follow the new rules in order for your patients to receive ESRD-related drugs.

MCP physicians and practitioners must:

  • Indicate on an ESRD patient’s prescription when a medication is not ESRD-related so payment for these non-ESRD-related medications is made under Part D.
  • If a lab is performed in office and is not related to ESRD, please append modifer AY and supply a non ESRD diagnosis.

ESRD facilities must:

  • Instruct patients to obtain their ESRD-related medications from ESRD facility-contracted pharmacies to ensure that pharmacies receive payment from the ESRD facilities and patients receive their medications with no financial obligation.
  • Instruct physicians and practitioners who receive MCPs to manage ESRD patients, to direct their patients to use ESRD facility-contracted pharmacies to ensure that pharmacies receive payment from the ESRD facilities and patients receive their medications.
  • Indicate on ESRD claims each ESRD-related drug (except for composite rate drugs) furnished to an ESRD patient either directly or through a prescription filled by a pharmacy.
  • Use the AY modifier on ESRD claims for each non-ESRD-related drug furnished to an ESRD patient.
  • Instruct home dialysis patients currently under Method II about any changes in the arrangements for ESRD-related home dialysis supplies and that patients no longer have any financial obligation to suppliers for ESRD-related supplies on or after January 1, 2011. 

ESRD patients may obtain covered Part D non-ESRD-related prescription drugs from a network pharmacy or an out-of-network pharmacy in accordance with Part D rules.

For more information visit:

Also, remeber beginning January 1, 2011 a home-based dialysis patient must have one face-to-face visit with a provider per month.  Visit our prior blog post for details.


Are Practices Really Exempt from Red Flag Rules?

December 29th, 2010

We received this today from healthcare attorney, Charles Key.

Clients and Friends:
According to a recent posting by the American Medical Association, President Obama on December 18, 2010 signed into law the "Red Flag Program Clarification Act of 2010," passed by both houses of Congress December 8.  According to the AMA summary, the law clarifies the application of the controversial Federal Trade Commission "Red Flags Rule" so as to apply only to creditors who, in the ordinary course of business, either (1) obtain consumer reports in connection with credit transactions, (2) furnish information to credit reporting agencies, or (3)make loans.  Most medical practices (as well as law firms, accounting firms, and other professional practices) will thus not be subject to the Red Flags Rule as clarified by the new law.  Those that are subject to the Rule must comply by this Friday, December 31, 2010.
The Red Flags Rule requires non-exempt creditors to adopt written policies designed to detect, prevent, and (where found) mitigate identity theft.  For more information, see the AMA's full posting at

CharlesCharles Key | Wyatt, Tarrant & Combs, LLP | 1715 Aaron Brenner Drive, Suite 800 | Memphis, Tennessee 38120-4367 | Direct dial (901) 537-1133 | Mobile (901) 481-3321 | Fax (901) 537-1010 |


Debridement Codes "Excised" for 2011

December 27th, 2010

For 2011, the AMA has expanded the Integumentary System subsection to include new guidelines to define debridement.  The Excision and Debridement subsection (11000-11047) went through extensive changes.

The familiar codes 11040 and 11041 are gone.  In a parenthetical note under the codes' old location is a note reading, "For debridement of skin, i.e., epidermis and/or dermis only, see 97597, 97598.” 

97597 and 97598 are wound care codes that require active wound care procedures to remove devitalized and/or necrotic tissue and promote healing.  97597 is for 20 square centimeters or less.  97598 is an add on code.  97598 is used in addition to 97597 for each additional 20 square centimeters or part thereof.  These codes are not to be used in addition to codes 11042 through 11047.

The documentation to support selective 97597 and 97598 should include the following:

  • Types of instruments used for selective debridement (i.e. high-pressure waterjet, scissors, scalpel, forceps);
  • Assessment of the wound including drainage, color, texture, temperature, vascularity, condition of surrounding tissue, and size of the area to be targeted for debridement.

If the provider treats with a nonselective method (such as a whirlpool) prior to using selective debridement, for the wound during the same visit, then only the selective debridement is reimbursable.  A modifier 59 should only be used 59 if two different wounds are treated with the different modalities.  Clearly note the location of each wound and the treatment associated with each wound.

CPT code 11042 has been revised to read “debridement, subcutaneous tissue (includes epidemis and dermis, if performed); first 20 square centimeters or less.”   Add on code 11045 is new and covers each additional 20 square centimeters of part thereof.

11043 is used for the first 20 square centimeters muscle and/or fascia.  11046 is the add on code for each additional 20 square centimeters of part thereof.

Note that the add on codes are frequently out of numerical order.

Debridement of burn wounds remain 16020-16030.


Changed Requirements for Home Health Care Certification for 2011

December 20th, 2010

Beginning January 1, 2011 a physician who certifies Medicare home health services must see the patient within 90 days before or 30 days after the home health certification.  Although a NPP still cannot certify a patient for home health services, the required exam may be provided by a NPP who works incidental to or in collaboration with the physician.

The physician will be required to document when he had a face-to-face encounter with the patient and to document how the patient’s clinical condition supports the need for skilled home health services as part of the certification form.  Attachments to the form are also acceptable.  Thus a physician may wish to include the required elements in his note for the date of service to support the certification.  The note could then be attached to the certification form.

The new requirements does have some positives for physicians:

  • A NPP may provide the face-to-face encounter,
  • A hospitalist may certify the need for home health care based on their face to face contact with the patient in the hospital,  establish and sign the plan of care the transfer care to another physician, and 
  • In rural areas, the law allows the face-to-face encounter to occur via telehealth, in an approved originating site.   

To learn more visit the Medicare Learning Network website at:

Home health care certifications and recertifications is an area frequently missed by physicians.  Care 

In order to bill for managing patients in home health care, you simply use code G0180 for initial certification, and G0179 for each follow up.  Certification and recertification pays approximately $30 to $40.

If you document phone calls and faxes, and keep copies of the certifications in the chart, you can bill for these services.  The payment for managing these patients is approximately $70 per month.

Of course, always document.

Care Plan Oversight activities that are BILLABLE include as part of Care Plan Oversight include:

  • Communication with interdisciplinary team and pharmacist, including phone calls or other verbal communication.
  • Review of patient status reports.
  • Modification of plan of care, including the review and signing of modification orders.
  • Review of lab results, reports, and records.

Care Plan Oversight billing criteria:

  • Patient must be receiving Medicare covered home health services.
  • Physician must document that 30 minutes or more of supervision to the patient’s care has occurred
  • Physician must have seen the patient at least once during the six-month period prior to Care Plan Oversight billing.
  • Physician is the only physician billing for Care Plan Oversight for the particular patient.
  • The physician billing for Care Plan Oversight must be the physician who signed the home health plan of care or the physician who was received the "hand off" for monitoring the care..

Other considerations:

  • Always retain the home care Plan of Treatment in the patient’s medical record.
  • Minimum billable time is 30 cumulative minutes dedicated to the patient’s care over a 30-day period. Document the time in the patient's medical record.
  • Care Plan Oversight activities cannot relate to post-op periods in global surgery packages UNLESS patient is being monitored for an unrelated condition.

To help you capturing Home Health Care Plan Charges, KLA has developed a tracking form for your use.


Services With Waived Deductibles and Coinsurance for 2011

December 15th, 2010

Yes, we're starting to sound like a broken record...but this is so important to your bottom line. 

If you want to avoid a little of the cash flow crunch in early 2011, book and bill services with waived coinsurance and deductible.

We've found a list CMS sent to its Contractors about implementing this.  Yes, we will eventually see a MLN Matters release on it; but we haven't yet.

To see the COMPLETE list of services for which Medicare will be waiving deductibles and coinsurance, visit:

Deductible and Coinsurance for Preventive Services 

This is good information to share with your provider friends.


Annual Wellness Visit (AWV), Including Personalized Prevention Plan Services (PPPS)

December 14th, 2010

We waited and waited on a Medicare Learning Network publication on the annual wellness visits before publishing yesterday's newsletter.  Guess what?  Today one was finally published!

Two new HCPCS codes, G0438 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), first visit, (Short descriptor – Annual wellness first) and G0439 - Annual wellness visit, includes a personalized prevention plan of service (PPPS), subsequent visit, (Short descriptor – Annual wellness subseq) will be implemented January 1, 2011

You can view the official "word" from Medicare on the new wellness exam benefits at:

The article details nicely what is required to be documented for the visit.  Remember, the wellness visits begin after a patient has completed one year with Medicare.  The first year the patient should be given the IPPE exam.  For information on documenting that exam visit:

A patient's first Annual Wellness Visit pays approximately $115 and is not subject to either coinsurance or deductibles.  Subsequent Annual Wellness Visits pay about $77.

Remember too that this is a requirement of the Affordable Care Act.  Unless an insurance company has applied for or falls under an exception, similar benefits should be available for ALL PATIENTS!



Health Care Law Found Unconstitutional by Federal Judge

December 13th, 2010

Today's New York Times reports:

"A federal district judge in Virginia ruled on Monday that the keystone provision in the Obama health care law is unconstitutional, becoming the first court in the country to invalidate any part of the sprawling act and insuring that appellate courts will receive contradictory opinions from below." Judge Henry Hudson declined "the plaintiff's request to freeze implementation of the law pending appeal, meaning that there should be no immediate effect on the ongoing rollout of the law."

Judge Hudson sought to sever those portions of the health care law that violated the Constitution rather than striking down the entire statute.  The provision in question would require everyone to have health insurance or pay a fine.

The opinion states: "'Neither the Supreme Court nor any federal circuit court of appeals has extended Commerce Clause powers to compel an individual to involuntarily enter the stream of commerce by purchasing a commodity in the private market.  In doing so, enactment (of the mandate to purchase insurance) exceeds the Commerce Clause powers vested in Congress under Article I (of the Constitution)"

To date, two other District Courts, one also in Virginia and another in Michigan, have upheld the law.

Contradicting opinions from different districts paves the way for a hearing in the U.S. Supreme Court.

There are more suits pending.


Congress Passes One Year SGR Fix. President Obama Promises to Sign

December 9th, 2010

The House of Representatives passed legislation this morning that prevents a 24.9 percent Medicare payment cut to providers that was scheduled to take effect on January 1, 2011 under the SGR formula.  The measure unanimously passed the Senate yesterday.  There was bipartisan support for the bill.

The extension will allow Congress and the White House to revisit the SGR formula responsible for the budgeted cuts.  With the first of the Baby Boomers reaching Medicare age during 2011, the way physicians are paid must be addressed or even more substantial cuts than those forecast are inevitable.

Per the AMA, "The joint efforts of AARP, the military community, AMA and other physician groups helped make this one year delay a reality for patients and their physicians.”

The President supports the bill and it should be signed into law shortly.


Finally - Medical Practices Aren't Creditors

December 7th, 2010

It's not completely official yet, but On December 7, the House passed the Red Flag Program Clarification Act of 2010. The Red Flags Rule requires financial institutions and creditors to develop and implement a written identity theft program. 

Several Physician organizations have lobbied to have medical providers exempted from the definition of Creditor.  This legislation would exempt health care providers from the Red Flags Rule requirements that go into effect January 1, 2011. 

The Senate passed similar legislation on November 30.  This legislation will now be sent to the President for signature.

Despite the exemption, most providers are still required to verify the patients identity under the policies of third party payor contracts.  It remains good policy to obtain picture identification of new patients.


New Q Codes Required For Billing Flu Vaccines to Medicare

December 6th, 2010

CMS has created specific HCPCS codes and payment rates for Medicare billing purposes for this flu season. Effective for claims with dates of service on or after January 1, 2011, CPT code 90658 will no longer be paid by Medicare.  As of October 1, 2010, the following new influenza Q codes became payable by Medicare:      Q2035 (Afluria),      Q2036 (Flulaval),      Q2037 (Fluvirin),      Q2038 (Fluzone), and      Q2039 (Not Otherwise Specified                  flu vaccine).
However, providers using these codes will not be paid for using these codes immediately.    The Medicare contractors’ have until February 7, 2011 to program their software to accept the codes. Medicare institutional providers also have the option to hold their claims containing the new influenza Q codes until February 7, 2011. Best advice:  vaccinate before the end of the year and use the old, still accepted codes.  After January 1, use the new Q codes.  
For further information, please see


For 2011 Home Dialysis Patients Must Have Face to Face Visit

December 1st, 2010

Effective January 1, 2011, the dialysis monthly capitation payment requires the provider to have at least one face-to-face patient visit per month with the patient for the home dialysis MCP service as described by CPTs 90963, 90964, 90965, and 90966.

Medicare contractors may waive the requirement for a monthly face-to-face visit for the home dialysis MCP service on a case by case basis; for example, when the nephrologist’s notes indicate that the physician actively and adequately managed the care of the home dialysis patient throughout the month.

For the Medicare Learning Matters article on topic visit:


PreAuthorizations Impact Care Negatively

November 26th, 2010

The AMA has recently published findings from a survey querying over 2,400 physicians on the impact preauthorizations with an insurance company had on overall patient care.  For those endlessly frustrated by obtaining such preauthorizations, the results were no surprise.

According to the story at

  • More than one-third (37%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for tests and procedures. More than half (57%) of physicians experience a 20 percent rejection rate from insurers on first-time preauthorization requests for drugs.


  • Nearly half (46%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for tests and procedures. More than half (58%) of physicians experience difficulty obtaining approval from insurers on 25 percent or more of preauthorization requests for drugs.


  • Nearly two-thirds (63%) of physicians typically wait several days to receive preauthorization from an insurer for tests and procedures, while one in eight (13%) wait more than a week. More than two-thirds (69%) of physicians typically wait several days to receive preauthorization from an insurer for drugs, while one in ten (10%) wait more than a week.


Three New Subsequent Observation Codes for 2011

November 22nd, 2010

CPT 2011 has a new section for Subsequent Observation Codes in the Hospital Care sections.  Observation Codes are a hot topic with the OIG.  It's not enough for the patient to be in the observation unit, the provider must also document the level of care appropriately.

The new codes are similar to the inpatient subsequent care codes, in that they include an interval history, a history that “focuses on the period of time since the physician last performed an assessment of the patient” according to the CPT Assistant.

The new codes are defined by the AMA's CPT as follows:

  • 99224 -- Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; problem focused examination; medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient's and/or family's needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient's hospital floor or unit.


  • 99225 -- Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; an expanded problem focused examination; medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit.


  • 99226 -- Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; a detailed examination; medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/ or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit


A Little New, More Old for Sleep Studies for 2011

November 17th, 2010

There are two new codes for unattended sleep studies for 2011 that pay significantly more than attended sleep studies by CMS.  

According to the AMA’s 2011 CPT Code Handbook  the full narrative for the new CPT Codes are:

95800: Sleep Study, unattended simultaneous recording, heart rate, oxygen saturation, respiratory analysis (eg by airflow or peripheral arterial tone), and sleep time.

95801: Sleep study unattended minimum of heart rate, oxygen saturation and respiratory analysis (eg by airflow or peripheral arterial tone).

The codes differ slightly.  For example, 95800 includes recording sleep time.  95801 captures a minimum heart rate.

The National CMS rates for these codes is high.  Currently 95800 allows $1,000 and 95801 allows $1,700.  Professional societies, including the AMA, are questioning these reimbursement rates and have asked for clarification.  Expect a correction.

Beware before using these codes with private insurers.  Many Blue Cross carriers, for example, have already announced the will not pay these codes and will consider these codes to be excluded by contract.

We still only have temporary code for home study tests.  The codes remain:

G0398:  Home sleep study test (HST) with type II portable monitor, unattended; minimum of 7 channels: EEG, EOG, EMG/heart rate, airflow, respiratory effort and oxygen saturation.  Approximate 2011 Reimbursement:  $115.

G0399:  Home sleep study test (HST) with type II portable monitor, unattended; minimum of 4 channels: 2 respiratory movement/airflow, 1 ECG/heart rate and 1 oxygen saturation.  Approximate 2011 Reimbursement:  $115.

G0400:  Home sleep test (HST) with type IV portable monitor, unattended; minimum of 3 channels.  Approximate 2011 Reimbursement:  $115.

As for the traditional sleep lab codes, some will increase. Others, decrease.  There is decrease in the physician value of sleep studies and an increase in the malpractice component.  The technical component went up in some cases and down in others. 

Following are the additional sleep lab codes for 2011 and their 2011 “national” reimbursement amount and the change from 2010 to 2011. 

                                                                                2011 National Rate/Change

95803                           Actigraphy testing                                 $176.25, +$55.68

95803-TC                      Actigraphy testing                                 $125.74, +$55.31

95803-26                      Actigraphy testing                                 $  50.52, +$ 0.37

95805                           Multiple sleep latency test                      $ 446.90, +$51.25

95805-TC                      Multiple sleep latency test                    $379.79,  +$77.06

95805-26                      Multiple sleep latency test                      $  67.11,  -$25.81

95806                                  Sleep study unattend & resp effort         $198.38,  -$ 5.90

95806-TC                      Sleep study unattend & resp effort         $130.16, +$ 8.11

95806-26                      Sleep study unattend & resp effort         $  68.21, -$14.02

95807                           Sleep study attended                            $511.80, +$32.45

95807-TC                      Sleep study attended                            $443.21, +$45.35

95807-26                      Sleep study attended                            $  68.58,  -$12.91

95808                           Polysomn 1-3 channels                          $707.59, +$38.72

95808-TC                      Polysomn 1-3 channels                          $609.88, +$71.90

95808-26                      Polysomn 1-3 channels                          $  97.71, -$33.19

95810                           Polysomnograph 4 or more                   $756.26, -$12.91

95810-TC                      Polysomnograph 4 or more                   $619.83, +$23.23

95810-26                      Polysomnograph 4 or more                   $136.43, -$36.14

95811                           Polysomnography w/cpap                     $816.00, -$32.08

95811-TC                      Polysomnography w/cpap                     $673.67, +$10.70

95811-26                      Polysomnography w/cpap                     $142.33, -$42.77

Sleep studies, particularly hospital based sleep studies, have become a push-button topic for the Office of Inspector General (OIG). So far during 2010, the OIG has issued three advisories regarding sleep studies.  These deal primarily with the relationship between the provider of sleep studies and the hospital.

Also RAC auditors have been charged with identifying improper place of service and improperly billed services.  Thus, knowing which code properly represents the sleep study you perform is important.

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New Coding for Administration of Immunization for 2011

November 15th, 2010

Effective January 1, 2011, immunization codes 90465-90468 will be gone. 

Replacing them are new codes 90460 and add-on code 90461.   The new codes recognize the counseling given to pediatric patients and their families concerning the risks and possible side effects of the immunizations.

Counseling may be given by the physician or qualified health care professional such as a nurse practitioner or a physician assistant at the time of service.  Registered nurses and medical assistants are not qualified health care professionals.  Counseling provided by them do not qualify for 90460 and 90461.

Compliance Alert:  Be sure to record a note about the counseling component associated with immunization as these are component of the CPT code definition.  Also, avoid charging a separate evaluation and management code for the visit unless significant, medically necessary services are provided.

Per CPT, the new codes are defined as:

90460 - Immunization administration through 18 years of age via any route of administration, with counseling by physician or other qualified health care professional; first vaccine/toxoid component.

+90461 each additional vaccine/toxoid component (List separately in addition to code for primary procedure)

If counseling is NOT provided, codes 90471 through 90474 should be used instead.

Codes 90460 and add-on code 90461 are reported per vaccine or toxoid component. Per CPT notes a component is a single antigen in a vaccine that prevents disease caused by a single organism.  Thus if a vaccine contains multiple antigens, the vaccine is a combination vaccine.

Multiple units of code 90460 may be reported for each first vaccine or toxoid component administered. No modifier should be required when reporting multiple first components.   90460 applies to combination vaccines and to single component vaccines such as influenza. Code 90461 is an add-on code reported for each additional vaccine component administered.

Modifiers are not required for multiple vaccines.

Coding Example:

The following example of the use of the new administrative codes is from the AAFP website:

An 11-year old girl presents for a preventive visit (99393). In addition, the child and her mother are counseled by the physician on risks and benefits of HPV (90649), Tdap (90715) and seasonal influenza administers each vaccine, completes chart documentation and vaccine registry entries, and verifies there is no immediate adverse reaction.

CPT Codes reported are:
99393 - Preventive Service
90649 - HPV vaccine
90460 - Administration first component (1 unit)
90715 - Tdap vaccine
90460 - Administration first component (1 unit)
90461 - 2 additional components (2 units)
90660 - Influenza vaccine, live, for intranasal use
90460 - Administration first component (1 unit)



2011 CPT Introduces New Ophthalmological Codes, Revises Others

November 12th, 2010

The following new and revised codes will be listed in the 2011 CPT Coding Manual and are effective January 1, 2011.

Code 92135 was one identified by the AMA as subject to misuse.  Further, the use of this testing has grown substantially.  Thus the code has been deleted and replaced with the following:

  • 92132 - Scanning computerized ophthalmic diagnostic imaging, anterior segment, with interpretation and report, unilateral or bilateral (Replaces 0187T)
  • 92133 - Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; optic nerve
  • 92134  - Scanning computerized ophthalmic diagnostic imaging, posterior segment, with interpretation and report, unilateral or bilateral; retina

The Ophthalmoscopy codes have also been revised to include the following codes to report remote imagining for screening retinal disease and management of active retinal disease.  Per AMA's Changes: An Insider's View:  "These codes are required to meet the needs of diabetic retinopathy screening programs, which provide remote imaging and data sumission to a centralized reading center."

  • 92227 - Remote imaging for detection of retinal disease (e.g., retinopathy in a patient with diabetes) with analysis and report under physician supervision, unilateral or bilateral.  Do not report this code with 92002-92014, 92133, 92134, 92134, 92250, 92228 or with an E&M based on a single organ system.
  • 92228 - Remote imaging for monitoring and management of active retinal disease (e.g., diabetic retinopathy) with physician review, interpretation and report, unilateral or bilateral.  Do not report this code with 92002-92014, 92133, 92134, 92134, 92250, 92228 or with an E&M based on a single organ system

Additional ophthalmological coding changes/revisions include:

  • 66174 - Transluminal dilation of aqueous outflow canal; without retention of device or stent (Replaces 0176T)
  • 66175 - Transluminal dilation of aqueous outflow canal; with retention of device or stent (Replaces 0177T)
  • 65778 - Placement of amniotic membrane on the ocular surface for wound healing; self-retaining
  • 65779 - Placement of amniotic membrane on the ocular surface for wound healing; single layer, sutured
  • 65780 - Ocular surface reconstruction; amniotic membrane transplantation, multiple layers
  • 66761 - Iridotomy / iridectomy by laser surgery (e.g., for glaucoma) (per session)



New CLIA Waived Labs for 2010

November 8th, 2010

CMS has issued an MLN Matters article about new CLIA Waived Labs for 2010.  You may view the article at:

The new labs which may be reported by waived labs by adding the modifer QW are:

CPT Code             Effective Date          Description

G0430QW                   January 1, 2010            American Screening Corp. OneScreen Drug Test Cups

84443QW                   March 2, 2010              Aventir Biotech LLC, Forsure TSH Test {Whole Blood}

84443QW                   March 4, 2010              BTNX, Inc Rapid Response TSH Test Cassette

G0430QW                   April 21, 2010              CLIAwaived, Inc. Rapid Drug Test Cup {OTC}

G0430QW                   April 21, 2010              Millennium Labs Clinical Supply Multi-Drug Pain Med Screen Cup

G0430QW                   May 10, 2010               US Diagnostics ProScreen Drugs of Abuse Cup {OTC}

G0430QW                   July 1, 2010                  Ameditech, Inc ImmuTest Drug Screen Cup

G0430QW                   July 4, 2010                  Quik Test USA, Inc. Multi-Drug of Abuse Urine Test

G0430QW                   July 4, 2010                  Screen Tox Multi-Drug of Abuse Urine Test

82274QW,G0328QW   July 8, 2010                  Consult Diagnostics iFOBT

G0430QW                   July 19, 2010                Alfa Scientific Designs Drug of Abuse Urine Cassette Test

G0430QW                   July 19, 2010                Alfa Scientific Designs Drug of Abuse Urine Cup Test

G0430QW                   August 18, 2010           American Screening Corp. Reveal Multi-Drug Test Cup

87880QW                   August 18, 2010           PSS Consult Diagnostics Strep A Dipstick

Many of these drug testing kits are available over the counter should a parent wish to perform drug tests in the privacy of the home.

For a complete list of waived tests visit:


2011 CPT Changes

November 5th, 2010

This excellent recap of 2011 changes is from

Evaluation and Management – 3 New Codes

99224 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: Problem focused interval history; Problem focused examination; Medical decision making that is straightforward or of low complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is stable, recovering, or improving. Physicians typically spend 15 minutes at the bedside and on the patient’s hospital floor or unit.

99225 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: An expanded problem focused interval history; An expanded problem focused examination; Medical decision making of moderate complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is responding inadequately to therapy or has developed a minor complication. Physicians typically spend 25 minutes at the bedside and on the patient’s hospital floor or unit

99226 - Subsequent observation care, per day, for the evaluation and management of a patient, which requires at least 2 of these 3 key components: A detailed interval history; A detailed examination; Medical decision making of high complexity. Counseling and/or coordination of care with other providers or agencies are provided consistent with the nature of the problem(s) and the patient’s and/or family’s needs. Usually, the patient is unstable or has developed a significant complication or a significant new problem. Physicians typically spend 35 minutes at the bedside and on the patient’s hospital floor or unit.

Integumentary System – 3 New & 2 Deleted codes

New CPT codes (Add-on Codes)

11045 - Debridement Subcutaneous Tissue, each additional 20 sq cm
11046 - Debridement Muscle/Fascia, each additional 20 sq cm
11047 - Debridement Bone, each additional 20 sq cm

Deleted codes

11040 & 11041 Debridement; skin; partial & full thickness

Musculoskeletal System – 5 New Codes


Respiratory System – 4 New Codes


Cardiovascular System – 20 New & 23 Deleted

New CPT codes


Deleted Codes

35454 – 35474 Transluminal balloon angioplasty
35480 - 35495 Transluminal peripheral atherectomy
39520 - 39531 Repair, diaphragmatic hernia

Digestive System – 18 New & 4 Deleted

New CPT codes


Deleted Codes

43324 - Esophagogastric fundoplasty (eg, Nissen, Belsey IV, Hill procedures)
43325 - Esophagogastric fundoplasty; with fundic patch (Thal-Nissen procedure)
43600 - Biopsy of stomach; by capsule, tube, peroral (1 or more specimens)
49420 - Insertion of intraperitoneal cannula or catheter for drainage or dialysis; temporary

Urinary System – 1 New Code

53860 - Transurethral Radiofrequency Treatment for Stress Incontinence

Female Genitourinary System – 1 New Code

57156 - Insertion of Vaginal Brachytherapy Device

Nervous System – 8 New & 2 Deleted codes

New CPT Codes

61781 - Stereotactic Computer Assisted PX IDRL CRNL
61782 - Stereotactic Computer Assisted PX XDRL CRNL
61783 - Stereotactic Computer Assisted PX SPINAL

Deleted CPT codes

61795 - Stereotactic computer-assisted volumetric (navigational) procedure, intracranial, extracranial, or spinal (List separately in addition to code for primary procedure)
64573 - Incision for implantation of neurostimulator electrodes; cranial nerve

Eye and Ocular Adnexa – 4 New Codes


Radiology – 5 New Codes


Pathology & Laboratory–15 New & 13 Deleted codes

New CPT codes


Deleted codes

82926 - Gastric acid, free and total, each specimen
82928 - Gastric acid, free or total, each specimen
86903 - Blood typing; antigen screening for compatible blood unit using reagent serum, per unit screened
89100 - Duodenal intubation and aspiration; single specimen (eg, simple bile study or afferent loop culture) plus appropriate test procedure
89105 - Duodenal intubation and aspiration; collection of multiple fractional specimens with pancreatic or gallbladder stimulation, single or double lumen tube
89130 - Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology;
89132 - Gastric intubation and aspiration, diagnostic, each specimen, for chemical analyses or cytopathology; after stimulation
89135 - Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 1 hour
89136 - Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 2 hours
89140 - Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 2 hours including gastric stimulation (eg, histalog, pentagastrin)
89141 - Gastric intubation, aspiration, and fractional collections (eg, gastric secretory study); 3 hours, including gastric stimulation
89225 - Starch granules, feces
89235 - Water load test

Medicine – 39 New & 41 Deleted codes

New CPT codes


Deleted Codes

Immunization Administration

90465 - Immune admin 1 inj,
90466 - Immune admin addl inj,
90467 - Immune admin o or n, 1 inj,
90468 - Immune admin o/n, addl inj,

91000 Esophageal intubation


91011 - Esophagus motility study w mechoyl
91012 - Esophagus motility study w acid perfusion studies 91052 - Gastric analysis test

91055 - Gastric intubation for smear
91105 - Gastric intubation treatment
91123 - Irrigate fecal impaction
92135 - Ophth dx imaging post seg

Electrocardiographic services

93012 - Transmission of ecg
93014 - Report on transmitted ecg

Ambulatory ECG Monitoring

CPT codes 93230 - 93237

Heart Catheterization and Injection procedure Codes

93501 - Right heart catheterization
93508 - Cath placement, angiography
93510 - Left heart catheterization; percutaneous
93511 - Left heart catheterization; by cutdown
93514 - Left heart catheterization by ventricular puncture

Combined Heart Catheterization

CPT codes 93524 - 93529

Injection procedures

CPT codes 93539 - 93545

Imaging Supervision

CPT codes 93555 - 93556

Chemotherapy Administration

96445 - Chemotherapy administration into peritoneal cavity, requiring and including peritoneocentesis


E-Prescribing Incentive Checks ALMOST in the Mail

October 22nd, 2010

E-prescribing incentive program are currently being processed, and should be wrapped up by the end of October. incentive payments will be paid as lump-sum to the TIN or the taxpayer ID under which the eligible professional’s claims were submitted.

It’s not too late to start participating in the e-prescribing program for 2010.  You can receive an incentive payment of two percent for participating in the program.  There are several FREE e-prescribing programs available online.  Check our resources pages for more information.

For 2010, there is a single code to report e-prescriptions:

G8553: At least one prescription created during the encounter was generated and transmitted electronically using a qualified eRx system.

Simply append the code to your claims to report that you used a qualified system to transmit one or more prescriptions electronically during the encounter.  You only need to report 25 non hospital claims for the year to qualify. 

If you could use two percent more of your Medicare dollar, e-prescribing is an easy first option.


Interim Relief for Reporting Cost of Group Healthcare Costs on W-2s

October 15th, 2010

A provision of the Patient Protection and Affordable Care Act requires employers to report the cost of healthcare coverage paid by the employer on their employees on Form W-2 beginning in tax years on or after January 1, 2011. The cost to be reported would be the "aggregate cost."  Per the IRS, the aggregate cost is "the 'applicable premium' under the rules providing for COBRA continuation coverage instead of the out of pocket cost paid by the employer.

The Treasury Department and IRS have extended interim relief from this requirement for 2011 to allow employers more time to update their payroll procedures to capture the "aggregate cost" data.

For more information visit:


Are You Capturing Nebulizer Education Codes?

October 8th, 2010


We admit it.  We're on a quest. 

We want to help you increase your reimbursement by capturing all the dollars you are entitled to but leave on the table.

Earlier this week, I saw a nurse teaching a patient how to use a nebulizer.  And yes, nebulizer education is a billable code. It does not need to be done by the provider, but must be done subject to a provider's orders.  This particular office had never billed for nebulizer education.

The CPT Code is 94664:  Demonstration and/or evaluation of patient utilization of an aerosol generator, nebulizer, metered dose inhaler or IPPB device.

When may you bill the code? 

94664 requires that education be given seperate from a nebulizer treatment. There must be a signed, written order in the chart for the education which documents medical necessity.  For example, a House episode showed a clinic patient using the inhaler as if it were perfume.  Dr. House could have easily written an order explaining the medical necessity of education.

Other more common reasons could be training for new nebulizer user or for a prescription for a new type of device.

If a medically necessary E/M service is provided on the same day as the nebulizer education, append modifier 25 (Significant, separately identifiable evaluation and management service by the same physician on the same day of the procedure or other service) on the office visit code (99201-99215).

Also beware that CCI edits bundle 94664 into inhalation treatment code 94640 (Pressurized or nonpressurized inhalation treatment for acute airway obstruction or for sputum induction for diagnostic purposes [e.g., with an aerosol generator, nebulizer, metered dose inhaler or intermittent positive pressure breathing [IPPB] device). However you may use modifier 59 to override the edit if the treatment and education are two SEPERATE events.How about reimbursement? 

The national Medicare Allowed on the procedure is $14.38. Considering Medicare allows $14.01 for the nebulizer treatment itself, if the practice demostrates the use of the nebulizer with the treatment, billing for education instead results in better reimbursement.  Of course, materials codes should also be included.

If nebulizer education is part of your routine practice, be sure to capture this frequently overlooked code.



Legal and Practical Issues of Billing and Collection Practices

September 25th, 2010

One of my favorite resources for staying up to date is the Med Law Blog published by Tucker Arsenberg Attorneys.  Michael Cassidy does a very nice job of keeping the blog updated with the practical impact of law changes.  Yesterday's post is applicable to everyone in private practice.  As such, I'm including it in full.

Legal and Practical Issues of Billing and Collection Practices Posted on September 24, 2010 by Michael Cassidy

Contributed by Michael Cassidy & Donna Kell

mcassidy [at] tuckerlaw [dot] com, djk [at] kellgroup [dot] com

An overlooked byproduct of health care reform and the general economic recession is the “multiplier” effect of larger deductibles and co-pays and the reduced ability of patients to make those payments, resulting in more collection problems and the perhaps unintended creation of consumer financing issues. This article is intended to address both the legal and practical issues of your billing and collection practices. 

I.          Legal Issues

Two legal issues that are often overlooked are the federal Truth in Lending Act (TLA) and the federal Fair Debt Collection Practice Act (Fair Debt Act).

Most physicians jump to the conclusion that the TLA does not apply to them because they are not engaged in consumer financing. However, TLA applies to any person who regularly extends consumer credit and the definition of consumer credit characterizes the transaction as one in which the party to whom the credit is extended is an actual person and the services which are the subject of the transaction are primarily for personal, family or household purposes -- this definition applies directly to the extension of credit for medical services and the TLA will apply if your practice meets either of these thresholds:

1.  You regularly extend credit, which is defined as extending credit more than 25 times per year; and

2.  The credit is either subject to a finance charge, or payable and subject to a written agreement in more than four installments.

Interest, or “the finance charge,” does not include charges for actual, but unanticipated late payment, for exceeding a credit limit, or for events of default or delinquency such as checks returned for insufficient funds.

If you are extending credit and subject to TLA, then you should consult with your lawyer to prepare the necessary disclosure documents necessary for the Truth in Lending Disclosures, which are basically the same documents you receive in any of the lending transactions in which you may have been involved.

The Fair Debt Act makes it unlawful for anyone to give a consumer, in this case the patient, the false belief that the person other than the creditor is participating in the collection process. For example, if you threaten to turn patients over to a collection agency, but actually have no arrangements to do so, you are violating the Act. Therefore, you should follow the following guidelines with regard to compliance with the Fair Debt Collection Practice Act:

1.  Do not threaten to refer a bill to a collection agency or take any other action unless you plan to do so or regularly do so with others;

2.  Do not disclose to any third party, over the phone or otherwise, that you are attempting to collect a debt from a patient;

3.  Do not send correspondence which reveals collection activities, such as post cards, envelopes with “past due” stamped on the outside;

4.  Do not call patients before 8:00 a.m. or after 9:00 p.m. or at work if you know they are not permitted to take personal calls; and

5.  You may not call a patient directly if the patient has advised you they are represented by counsel.

II.  Practical Issues

In order to ensure that your medical practice is compliant, it is prudent to create a self-pay financial policy. A written financial policy not only helps your office support staff to be consistent in how self-pay collections are implemented, but also allows your patients who have self-pay balances to know what to expect from your practice. 

Consider including the following elements into your policy:

1.  How and when your practice verifies patient insurance coverage. The person who verifies insurance should be instructed to document co-payment amounts by specialty and/or type of service into the patient chart so that office staff knows exactly what to collect from the patient on the date of service.

2.  Specifics about what the patient can expect for collection of other patient-responsible balances such as deductibles and co-insurance amounts. Explain the billing cycle to every patient. Inform them about your patient invoicing procedures; such as, the frequency of invoicing and the types of collection activities your practice employs.

3.  Patient Due Statements. Design a statement that is readable, that clearly identifies the balance due, specifies the due date, and clearly states how patients can contact your office.

4.  Bad Addresses. Create a procedure to quickly investigate patient statements that are returned to you due to a bad address. If you are unable to correct it, the patient chart should be flagged so that any future contact with the patient, including subsequent appointments and invoices, are halted until the address is updated.

5.  Reporting Bad Debt. If you determine that you want to affect a patient’s credit score, you may chose to sign-up with a credit bureau. Patients’ concerns about bad debt reporting may prompt them to pay you promptly.

6.  Financial hardship. What criteria does your practice utilize to reduce a patient-due balance? If your practice participates with Medicare, you need to be certain that you are charging all payers equally. This means that co-payments, deductibles and coinsurance amounts are not be written off subjectively.  Developing standard discounts that are based upon income guarantees that self-pay reductions are handled equitably and objectively.

7.  Payment methods that are accepted by the practice. For example: cash, checks, payment plans, debit cards, and credit cards. 

     i.      Cash – Collect co-payments on the date of service, preferably at patient check-out. Practices that collect at check-in may miss co-payments that are assessed by type of service. If you accept cash, be sure to have procedures in place for daily reconciliation.

     ii.      Payment Plans – Your policy should specify acceptable payment thresholds, with the goal being to collect all balances in three months or less. Determine if your practice management system has functions that can easily create payment coupons. This can help your patients to keep their payment commitment. If your financial policy allows for assessing interest, make sure that the system is set-up to follow TLA guidelines.

     iii.      Debit and Credit Cards - Think about ways to make it easy for your patients to pay their balances; including giving patients an online payment option.

After you’ve established your policy, take the time to train your front desk and billing staff. Practices can be exposed to legal liability simply due to an employee who is not appropriately trained or who is uncomfortable or incapable of accurately communicating with patients who are delinquent. 

Complete understanding of a well-designed financial policy, combined with frequent staff training and refresher seminars - especially with regard to the Fair Debt Act guidelines, patient communications, and conflict resolution techniques – can assure legal compliance, patient satisfaction and a steady cash flow regardless of the many economic changes that you face.


2011 Neurology CPT Code Changes

September 24th, 2010

Sleep Studies

CPT 2011 replaces the temporary G codes used for unattended sleep studies with new permanent codes:

95800 Sleep study, unattended, simultaneous recording; heart rate, oxygen saturation, respiratory analysis (eg, by airflow or peripheral arterial tone), and sleep time

95801 Sleep study, unattended, simultaneous recording minimum of heart rate, oxygen saturation, and respiratory analysis (eg, by airflow or peripheral arterial tone)

The codes differ by whether or not sleep time is included.  Assuming the SGR cut does not go into effect later this year, Medicare allowed for global 95800 will be about $925, and for global 95801, $1550.

CPT notes also advise Providers not to report ECG or sleep study services seperately when using 95800 or 95801

Muscle, Range of Motion Testing

The term "Tensilon" has been removed from CPT Code 95857.  The description is now:  Cholinesterase inhibitor challenge test for myasthenia gravis.

The change was necessary because the drug Tensilon is no longer available.

Intraoperative Neurophysiology

Following the description of the add-on code 95920, CPT 2011 adds a note that discusses how to count time.

Do not report 95920 if recording lasts 30 minutes or less. For procedures that last beyond midnight, report services using the day on which the monitoring began.

More on Counting Time

Count every 24 hours: 95950-95953 and 95956. For recording 12 hours or less, use modifier 52.

Count every hour of physician attendance95961 and 95962. Report 95961 for the first hour of physician attendance. Use modifier 52 with 95961 for 30 minutes or less. Report 95962 for each additional hour of physician attendance.


The AMA requested that 95953 and 95956 be revised to clarify attendance and unattendance.  The terminology of both were changed. 

Code 95953 is for an ambulatory EEG, which is not attended by a technologist or nurse.

Code 95956 is used now for monitoring without video. It requires attendendance during the recording. The code descriptors now read:

95953 Monitoring for localization of cerebral seizure focus by computerized portable 16 or more channel EEG, electroencephalographic (EEG) recording and interpretation, each 24 hours, unattended

95956 Monitoring for localization of cerebral seizure focus by cable or radio, 16 or more channel telemetry, electroencephalographic (EEG) recording and interpretation, each 24 hours, attended by a technologist or nurse


Smoking Related Disease No Longer Required For Tobacco Cessation Counseling

September 6th, 2010

On August 25 CMS announced a change in reimbursement policy for tobacco cessation counseling.  In the past, to bill for Tobacco Cessation Counseling, a smoking related disease diagnosis had to be linked to codes 99406 (three to ten minutes) and 99407 (more than ten minutes).

Medicare alloweds for these codes are approximately $13 and $25, slightly more or less depending on your jurisdiction.

CMS announced that “under new coverage, any smoker covered by Medicare will be able to receive tobacco cessation counseling from a qualified physician or other Medicare recognized practitioner who can work with them to help them stop using tobacco.”  Thus, the only diagnosis now required is 305.1, tobacco use disorder.

The new tobacco cessation counseling coverage expansion applies to services under Medicare Part B and Part A. “The new benefit will cover two individual tobacco cessation counseling attempts per year.Each attempt may include up to four sessions, with a total annual benefit thus covering up to eight sessions per Medicare patient who uses tobacco.”

“For too long, many tobacco users with Medicare coverage were denied access to evidence based tobacco cessation counseling,” said Kathleen Sebelius, HHS secretary, the August 25 statement. “Most Medicare beneficiaries want to quit their tobacco use. Now, older adults and other Medicare beneficiaries can get the help they need to successfully overcome tobacco dependence.”

Tobacco counseling must be done according to a plan.  The websites  and both have programs that may be adopted and used for counseling.  Simply telling a patient to quit smoking is not sufficient. 


CMS Expands Covered Telehealth Services for 2011

September 6th, 2010

CMS is adding the following requested services to the list of Medicare telehealth Services for 2011:

• Individual and group KDE services (HCPCS codes G0420 and G0421, respectively);

• Individual and group DSMT services, with a minimum of 1 hour of in-person instruction to be furnished in the initial year training period to ensure effective injection training (HCPCS codes G0108 and G0109, respectively);

• Group MNT and HBAI services (CPT codes 97804, and 96153 and 96154, respectively);

• Subsequent hospital care services, with the limitation of one telehealth visit every 3 days (CPT codes 99231, 99232, and 99233); and

• Subsequent nursing facility care services, with the limitation of one telehealth visit every 30 days (CPT codes 99307, 99308, 99309, and 99310).

CMS also limited the use of telehealth in two ways. First, for hospital care services, CMS limited the patient’s admitting physician or practitioner to one telehealth visit every 3 days. For subsequent nursing facility care services, CMS limited the patient’s admitting physician or non-physician practitioner to one telehealth visit every 30 days. Also, for DSMT, CMS required a minimum of 1 hour of in-person instruction to be furnished in the year following the initial training to ensure effective injection training.

For more information, visit:


Outstanding Review of Meaningful Use Published by NEJM

August 6th, 2010

The New England Journal of Medicine has published an outstanding description of the requirements for Meaningful Use in Electronic Health Records.  The article itemizes the objectives and the means of measuring a practice's compliance.

The article and chart may be read by clicking here:  

The “Meaningful Use” Regulation for Electronic Health Records


"Meaningful Use" For EHR Now Defined

July 14th, 2010

Yesterdary (July 13, 2010) CMS and ONC announced the final rules on Meaningful Use and Standards and Certification under the HITECH Act’s Electronic Health Records (EHR) incentive program.

You may find the final rule for meaningful use at:

The final rule on standards, implementation specifications, and certification criteria for EHR technology may be found at


No Signature Means No Order for Medicare Auditors

June 21st, 2010

One of the areas Medicare auditors are instructed to review during audits is the signatures of medical records.  In fact, if a required physician's signature is missing from an order that requires a signature, auditors have been instructed to completely ignore the medical record or order. 

CMS has recently updated MLN Matters Number MM698 to define what is a legible signature.  On pages six and seven of the bulletin, a chart that summarizes signature and legibility requirements is included.  See:

There are some surprises in the publication.  For example, signature by attestation is allowed.  A suggested format for the attestation is provided within the article.

Initials are only acceptable is over a typed name or accompanied by a signature log or attestation statement.

A dictated and typed medical report even if initialed is insufficient unless the physician initials over a typed name (or there is an accompanying signature log or attestation statement.)

Surprisingly, some items do not require a signture.  For example, orders for clinical diagnostic tests are not required to be signed. But if the order for the clinical diagnostic test is unsigned, there must be some form of documentation by the treating physician (e.g., a progress note) that he intended for the clinical diagnostic test to be performed. This documentation must be signed.

Not knowing and applying signature requirements could be a costly mistake.  The MLN Matters cited above should be mandatory reading.


ICD-9 Changes for 2011 Released

June 14th, 2010

The ICD-9 2011 codes will take effect October 1, 2010.  For diagnosis codes CMS does NOT allow a grace period to the first of 2011.  The codes must be used beginning October 1, 2010.

The proposed changes include 122 new codes thatl reflect CMS’s continued drive for greater specificity in diagnosis coding. There are 11 deleted and nine revised diagnoses codes.  54 of the 122 new codes are V codes.

Some of the new changes include:

New V Codes

V Codes compose the largest single group of changes..

V11.4 is a new history of code for Combat and operational stress reaction (COSR), for a past acute reaction to stress that might have been called combat fatigue or catastrophic stress in former years.

Codes V13.23, Personal history of vaginal dysplasia, and V13.24, Personal history of vulvar dysplasia, were created at the request of the American College of Obstetricians and Gynecologists for patients with dysplasia that required follow-up visits to ensure the condition had resolved.

Codes V25.11–V25.13, Encounter for insertion or removal or removal and reinsertion of intrauterine contraceptive device (IUD), was added. The current  code V25.42, Intrauterine contraceptive device (surveillance), is limited to checking the presence of the IUD.

Codes V13.61–V13.69, Personal history of (corrected) congenital conditions, recognize that many congenital conditions can be completely repaired.

The intent of new code V49.86, Do not resuscitate status, is to identify the patient who has a physician's order for "do not resuscitate" status.

Code V49.87, Physical restraint status, identifies patients who had restraints in place during their healthcare services. This code excludes the use of restraints due to procedures.

Code V62.85 was created to identify homicidal ideation.

New codes V85.41–V85.45, Body mass index 40 and over, adult, were added to provide greater specificity regarding BMI 40 and over for adults.

Two new codes (V88.11–V88.12, Acquired absence of pancreas) provide information about the acquired total absence and acquired partial absence of the pancreas organ.

Specific codes (V90.01–V90.9, Retained foreign bodies) were created to identify patients who have retained foreign fragments within their bodies, such as radioactive, metal, magnetic, plastic, organic, and other and unspecified fragments.

New codes (V91.00–V91.99, Multiple gestation placenta status) for use with pregnancy codes for multiple gestations (twin, triplet, quadruplet, and other specified multiples) to indicate the number of placentas and amniotic sacs present have been added.

The V91 category codes are used in addition to category 651 codes to describe the female's multiple gestation condition.

External Cause Status

E000.2 was added as a new External Cause Status to indicate the patient was acting as a volunteer when the event occurred that caused the patient to seek medical attention.

Acute Idiopathic Pulmonary Hemorrhage in Infants

The Centers for Disease Control and Prevention requested a specific code for acute idiopathic pulmonary hemorrhage in infants (AIPHI). This condition causes pulmonary hemorrhage in a previously healthy infant with a gestational age over 32 weeks and no prior medical problems. Subcategory 786.3, Hemoptysis, was expanded to include unspecified hemoptysis (786.30), AIPHI (786.31), and other hemoptysis (786.39).

Aortic Ectasia

New codes were created to classify aortic ectasia at different sites, including thoracic aortic ectasis (447.71), abdominal aortic ectasia (447.72), thoracoabdominal aortic ectasia (447.73), and ectasia of unspecified site of aorta (447.70). Aortic ectasia is a dilation of the aorta that may develop into an aneurysm over time.

Blood and Blood Products Transfusion Related Conditions

Several codes were added to capture different blood transfusion-related conditions. Code 275.02, Hemochromatosis due to repeated red blood cell transfusions, was added to recognize iron overload caused by repeated red blood cell transfusions. In addition, codes 275.01, Hereditary hemochromatosis; 275.03, Other hemochromatosis; and 275.09, Other disorders of iron metabolism were created to identify patients with hemochromatosis that may result in organ damage, including heart, kidney, and liver dysfunction.

A new code for transfusion-associated circulatory overload, or TACO (276.61), identifies patients with circulatory overload following a blood or blood component transfusion. The circulatory overload may follow large volumes of infusion that cannot be processed by the recipient or underlying cardiac or pulmonary pathology. Elderly patients and infants are at an increased risk for TACO, even with small transfusion volumes.

Code 287.41 was added to identify post-transfusion purpura (PTP), which produces a sudden severe thrombocytopenia (platelet count less than 10,000/µL) usually five to 12 days following transfusion of blood components. This reaction is associated with the presence of antibodies directed against the human platelet antigen system. Code 287.49 was also added to subcategory 287.4, Secondary thrombocytopenia, for other secondary thrombocytopenia conditions, such as those due to massive blood transfusions.

Code 780.66 was added for febrile nonhemolytic transfusion reaction (FNHTR), which may be referred to as a "post-transfusion fever." This condition, which can occur within four hours of a transfusion, includes fever, chills, and rigors. It may be a reaction between recipient antibodies and transfused leukocytes.

Numerous codes were created to classify hemolytic transfusion reactions (HTRs), an increased destruction of red blood cells due to incompatibility between blood donor and recipient. It can be acute or chronic depending on the timing of the occurrence. HTRs can be caused by either ABO or non-ABO incompatibility and can be fatal.

New codes were created in the following ranges:

  • 999.60–999.69, ABO incompatibility reaction due to transfusion of blood or blood products
  • 999.70–999.79, Rh and other non-ABO incompatibility reaction due to transfusion of blood or blood products
  • 999.80–999.89, Other and unspecified infusion and transfusion reaction

A simple diagnosis of "transfusion reaction" is coded to 999.80; however, requesting more specific information from the physician will produce more accurate coding and provide better information to report transfusion-related complications.

The Food and Drug Administration, Center for Biologics Evaluation and Research, requested the new codes for better tracking to decrease transfusion complications.

Cocaine Poisoning

A unique code for poisoning by cocaine or crack cocaine (970.81) was added to the table of drugs and chemicals for FY 2011.

Fecal Incontinence

Fecal incontinence can be caused by problems with the rectal and anal sphincters. It may first present with symptoms like fecal smearing, urgency, and incomplete defecation. Incomplete defecation is not synonymous with fecal impaction.

New codes were created for fecal impaction (560.32), fecal incontinence (787.60), incomplete defecation (787.61), fecal smearing (787.62), and fecal urgency (787.63).

Fluency Disorders

Code titles have been modified and new codes added to distinguish childhood onset fluency disorder, adult onset fluency disorder, and fluency disorder subsequent to brain lesion or disease.

The title of code 307.0 was changed from "stuttering" to "adult onset fluency disorder." Code 315.35 was added for reporting childhood onset fluency disorder. New code 784.52, Fluency disorders in conditions classified elsewhere, is used as an additional code with conditions such as Parkinson's disease that produce the fluency problem.


Subcategories 488.0, Influenza due to identified avian influenza virus, and 488.1, Influenza due to novel H1N1 influenza virus, were expanded to the fifth-digit level to identify pneumonia, other respiratory manifestations, and other manifestations that occur as a result of the virus infection. Codes 488.01, Influenza due to identified avian influenza virus with pneumonia, and 488.11, Influenza due to identified novel H1N1 influenza virus with pneumonia, require an additional code to identify the type of pneumonia.

Jaw Pain

Jaw pain may be a symptom of a myocardial infarction. For this reason, new symptom code 784.92 was created for jaw pain to classify the patient who presents with this complaint.


Code 237.73 was added to subcategory 237.7, Neurofibromatosis, to recognize Schwannomatosis, a genetic disorder that causes multiple tumors to grow on cranial, spinal, and peripheral nerves. Code 237.79 was also added to capture other neurofibromatosis conditions.

Neurogenic Claudication

Neurogenic claudication is associated with significant lumbar spinal stenosis, leading to compression of the cauda equine or lumbar nerves. It may require corrective surgery. Patients can have lumbar spinal stenosis without neurogenic claudication.

Code 724.03, Spinal stenosis, lumbar region, with neurogenic claudication, was created. Code 724.02, Spinal stenosis, lumbar region, without neurogenic claudication, was revised to distinguish between patients with and without neurogenic claudication.

Neurological Conditions

Six new signs and symptoms codes involving cognition were created to better classify traumatic brain injury (TBI) and its associated conditions (799.51–799.59). These codes describe cognitive impairments such as memory, concentration, attention, communication, and executive function.

The new codes can also be used to classify patients presenting with the same symptoms due to a neurological condition. The codes can be used as additional codes when the cause is known, such as TBI, and before a definitive diagnosis is made.

Obesity Hypoventilation Syndrome

Code 278.03 was added for obesity hypoventilation syndrome (OHS), also called Pickwickian Syndrome. OHS is a breathing problem that causes hypoventilation and produces decreased oxygen levels and elevated carbon dioxide.

Post-traumatic Seizures

New code 780.33 was created for post-traumatic seizures that are acute symptomatic seizures following a head injury. Post-traumatic seizures are not the same as post-traumatic epilepsy. Patients with post-traumatic seizures require follow-up to ensure complete resolution and prevent complications.

Reproductive Organ Congenital Anomalies

Congenital anomalies of the uterus, cervix, and vagina are collectively known as Müllerian anomalies. Vaginal and cervical anomalies are less common than uterine anomalies.

Seven new codes in the 752.31–752.39 range were created to identify uterine anomalies of

agenesis, hypoplasia, unicornuate, bicornuate, septate, arcuate, and other anomalies of the uterus. Codes 752.43–752.45 were created to identify cervical and vaginal anomalies, specifically cervical agenesis, cervical duplication, vaginal agenesis, transverse vaginal septum, and longitudinal vaginal septum.

To see the new, deleted and revised codes visit:

This site will be updated as revisions are made in the code set.




June 1 - Red Flag Warning!

May 27th, 2010

For over a year, we've been told by major medical associations that Red Flag Rules shouldn't apply to medical practices.  After all, most medical practices aren't very aggressive with their collection practices.  How often have you known a doctor to put a lien against someone's home because of an unpaid claim?  Thus why should a medical office be grouped with financial institutions as a purveyor of credit.

Still, identity theft is REAL in a medical office setting.  The oddity in a medical practice is that the theft is frequently done to the provider; not by him.

Physicians and other providers run the very real risk of their identity being stolen.  Most providers have encountered their DEA numbers being fraudulently used to obtain prescriptions.  Also most providers have experienced treating a patient for which Medicare already has a date of death.

It has long been a rule by many Medicaid carriers that a provider's office should verify identity BEFORE rendering treatment.  The use of Medicaid cards by those other than the patient covered is a major problem for most state plans.

A provider's office should have HIPAA policies in place that will go far to satisfying the Red Flag Rules.  Adding procedures such as obtaining a picture i.d. or reasonable substitute thereof will likely protect the provider more than it will the patient.

Free resources are available online to help prepare the required written policies.  The FTC itself has an online template for low risk businesses available at:

The American Medical Association also has a template available.  If you are a member, you can access a Word document that may be easily modified.  Everyone can access a pdf version.  See

The American Medical Association and others have filed a lawsuit to prevent the Red Flag Rules from applying to medical offices.  To read about the lawsuit, visit:

But honestly, with all the tools available, why not waive the white flag and comply. 


Online Appointment Scheduling

May 7th, 2010

A few weeks ago, I needed to make an eye appointment.  When doing a Google search to find my eye doctor's phone number,  I found she had an online scheduler.  The scheduler showed available appointments only.  There was not detail on the web view about who had what appointments. I was thrilled that I could book my appointment online. 

Several days before the appointment, I was sent an email reminder.  The day before the appointment I was sent another email reminder.

When I got to the doctor's office, I asked her wonderful receptionist about the software.  She said it worked great.  She used the same software to book the appointment in the office.   If you add a patient's email address, reminders will be sent.  It also includes a feature where the physician can make notes about the patient.

There's a little setup involved.  You need to define your visits.  For example, you could have new patient, established patient, laboratory only. 

The program can handle multiple providers and multiple sites.

If you'd like to try it out, go to the website  There's no charge for the first 30 days.  If you're a KLA client, the service will be free to you under our license. Just give me a call for the "promotional code."

Let me know what you think!




Our Updated Website

May 5th, 2010

KLA Healthcare Consultants is excited about our new website designed by the extraordinary RocketFuel.  The Rocket Fuel team is what they promise:  Intergalactic Web Experts In Our Neighborhood.

With our newly designed site we will be able to quickly post new resources and blog entries for the use of our clients and friends.  With the easy to use web interface, we can make these changes ourselves, from our desktops, as needed.

The Rocket Fuel animal lovers always include a picture of Bowtie the cat when launching a new website.

The employees of KLA share a love of animals.  Our combined pets include cats, dogs, birds and fish.  We even have a nest of baby finches on a lightpost outside our office.

Thank you Rocket Fuel.  We appreciate you.  In homage, we'll keep Knox in his bowtie for luck.  We'll  drink our champagne instead of breaking it over the bow of our new website.


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