Stay Abreast of Coding and Billing Changes with CMS Hot Topics

Balancing the Accounts

Medical billing and coding is constantly being updated. Billing/coding professionals and providers have a responsibility to stay abreast of these changes in order to maintain compliance, and one of the ways that the Centers for Medicare & Medicaid Services (CMS) communicate these changes is via their carrier websites under the title of “Hot Topics.” Hot Topics consist of published regulatory and interpretational/clarification changes relevant to the health care industry that pertain to all settings in which health care services are rendered. The bottom line of these communications is for billing/coding professionals and providers to understand the many different components involved in generating a clean and compliant claim.

What makes coding and billing issues hot topics?

  • New requirement in the language of a CPT-4 /ICD-9 code that is required in order to report to payers
  • Additions/deletions of CPT-4/ICD-9 dodes
  • Updated or new interpretations to a standing practice or health care reimbursement policy practice or policy
  • Provider errors that arise from the results of government audits and are now subject to investigation or under review by the OIG, HHS, CMS, RAC auditors, etc

What billing/coding professionals and providers have to remember is that all services must meet what CMS deems as “reasonable and necessary” in order to be reimbursed for services rendered to patients. The majority of commercial payers also follow these or similar guidelines. What CMS means by “reasonable and necessary” is that a service must be relevant to “reasonable and necessary” care for the diagnosis and treatment or must be rendered to “improve the functioning of a malformed body member.” Additionally, the service(s) must be considered “safe” and effective and not experimental in nature, must be appropriate and include the duration and frequency that would be considered suitable for the level of service provided. Lastly, all must be supported clearly in the provider’s documentation.

Examples of billing/coding hot topics

  • CPT code changes published every Jan. 1 – includes new, revised, and deleted codes
  • ICD code changes published every Oct. 1 – includes new, revised, and deleted codes
  • Provider signature legibility issues – signature legibility on documentation – requires signature log or attestation from provider that indicates signature is theirs – for validation and compliance
  • Provider e-signatures on electronic health records (EHR) must be closed by rendering provider not by another source and not left “open” for more than 24 hours for validation and compliance
  • Provider signatures on all orders – requires ordering providers signature for validation and compliance
  • High volume of reported outpatient claims greater than $50,000 – red flag for potential erroneous claims
  • High volume of reported inpatient claims greater than $200,000 – red flag for potential erroneous claims
  • Place of Service Errors – Outpatient/POS 22 VS Office/POS 11 – potential for erroneous services being reported under incorrect POS in order to recoup a higher reimbursement
  • Modifier use (25, 59) – modifier 25 potential for erroneous reporting of separate services, when they either were not provided or should be included in other service and the same for modifier 59
  • Incorrect leveling of an Evaluation and Management service (E/M level) – i.e., new patient visit billed instead of established patient visit as it has a higher reimbursement
  • Global Surgery Days Billing E/M level for post-operative visit, when the visit is included in the 90-day post-op period
  • Billing of E/M on the same day as a scheduled procedure for the same reason as procedure (it’s included) – can only bill if the decision for surgery was made the same day.
  • Teaching physicians (TP) at teaching hospitals using a checkbox in lieu of writing a linking statement that shows the TP was personally supervising
  • Medically Unnecessary Services – evaluation of services to determine if medical necessity has been met for a service based on payer coverage determinations
  • Cloning of electronic health records – when providers copy/paste the electronic documentation from one DOS for a patient into another – new DOS instead of taking new information for the visit – the OIG is concerned about “canned” documentation that does not reflect individual patient condition. Documentation that is copied from prior visits may not be relevant or medically related to the service
  • Coverage changes – National Coverage Determinations (NCDs) – Medicare often will issue a special policy determination for a service or procedure and once it is published all CMS providers/payers must adhere to the NCD
  • Local Coverage Determinations (LCDs) – These are published locally by Medicare Administrative Contractors (MAC). They clarify CMS policies and also make policy for services not discussed specifically by CMS. Additionally, they provide coding claims processing advice from payers to providers

Final Thoughts

It is important to remember that as a billing/coding professional, you are only as good as the information you review and keep abreast of. Sign up for email updates to stay ahead of regulatory changes that affect medical billing and coding and ensure compliance for yourself and your providers.

Hot Topic resources

The Society for Vascular Ultrasound publishes a list of all the Medicare Administrator Carrier’s websites; please click here to access it.


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