Medical Coding and Billing Articles
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Nov 6th, 2024
Consumer Health Plan Appeals
As part of the Patient Protection and Affordable Care Act (PPACA) of 2010, expanded appeal rights for patients have been granted in all states. These regulations grant the right to both an internal appeal through the insurance plan, as well as an independent external appeal.
Nov 5th, 2024
Designation of Authorized Representative for Appeals
A Designation of Authorized Representative is a formal document (form) that allows a third party, such as a friend, family member, attorney, or healthcare provider, to act on behalf of the patient/beneficiary in handling specific aspects of an insurance claim or appeal
Oct 31st, 2024
Managed Care Organizations (HMO, PPO, etc.)
Managed care is a type of health insurance system designed to reduce healthcare costs while ensuring high quality care through coordinated, cost-effective, and efficient delivery of services. Learn the characteristics of these types of programs.
Broadly speaking, managed care is a healthcare delivery system designed to control costs, improve quality, and manage how services are provided to enrollees. It integrates healthcare providers, hospitals, and insurers to coordinate patient care in a cost-effective way. Managed care often emphasizes preventive care, streamlined service delivery, and coordinated treatment plans.
Oct 31st, 2024
What Medicaid Information is in Find-A-Code?
Oct 30th, 2024
What are the Different Medicaid Payment Systems?
The Medicaid payment system, which funds healthcare for low-income individuals and families, is complex and varies by state. It generally works through a combination of fee-for-service (FFS) and managed care models, with federal and state governments sharing costs. This article contains information to help explain some of the different ways that Medicaid pays for healthcare services.
The Medicaid Chronic Illness and Disability Payment System (CDPS) is a diagnostic-based risk adjustment model used to calculate payments for Medicaid health plans, particularly for those covering individuals with chronic illnesses and disabilities.
A conversion factor is a dollar amount that is applied to an adjusted Relative Value Unit (RVU) to arrive at a fee. Conversion factors can be based on a geographic location as well as a national level. The article contains information from the Veterans Administration about how they create their geographically-adjusted 80th percentile conversion factors.
Aug 5th, 2024
Medicare Fee Schedule Information
Aug 1st, 2024
Telehealth Policies in the Post-Pandemic Era
by Kate Choi
Earlier this month, the Centers for Medicare & Medicaid Services (CMS) released its proposed Physician Fee Schedule for 2025 . A major component of the proposed rule is the telehealth policies, particularly given that major Medicare telehealth waivers are set to expire at the end of 2024. CMS has...
Jul 31st, 2024
Where are UCR Fees Located in Find-A-Code?
by Wyn Staheli, Director of Content - innoviHealth
UCR fees can be found in several places within Find-A-Code. The most commonly used place is found in the Fees section of the individual code. When you are on the code information page for a specific code, scroll down to the fees section and click on the bar titled “Fees” (as shown below) to open this section:
Jul 25th, 2024
Does the Pro Fee Calculator Include UCR Fees?
by Wyn Staheli, Director of Content - innoviHealth
Find-A-Code’s Pro Fee Calculator is an easy-to-use tool for calculating fees for CPT and HCPCS codes. Need to apply modifiers or additional units? The Pro Fee calculator can do this and much more. Check it out.
Jul 25th, 2024
Where does Find-A-Code get UCR Data?
by Wyn Staheli, Director of Content - innoviHealth
Find-A-Code provides UCR fees gathered from the US Department of Veterans Administration (VA) using Geographically-adjusted charges and the 80th percentile conversion factors; this information can be found on the code information page (see example below) and is available for performing a fee comparison with our UCR Pricing add-on.
May 22nd, 2024
Be Wary, But not Fearful, of False Claims Act Allegations
by David M. Glaser, Esq.
One of my favorite things to do is help clients extricate themselves from a False Claims Act investigation. I like it because it’s intellectually challenging, and few things are more rewarding than keeping an organization from having to pay large sums of money. Longtime readers know that False Claims...
Feb 14th, 2024
Information Sharing with the Feds is Risky Business
by David M. Glaser, Esq.
Over the last few weeks, a few articles of mine addressed interacting with government agents. One topic that I did not discuss was determining whether you can, should, or must share information with the government. Unfortunately, it’s not possible to definitively answer that question for every topic, even in...
Jan 10th, 2024
Government Shutdown Looming as Congress Dithers
by Matthew Albright
Like most of the world, I procrastinate when paying my bills. I tend to put them off until the very last minute. And that pretty much explains Congress’s strategy last year – and they clearly plan on continuing this approach for 2024. The tough stuff, like funding a government,...
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
We constantly hear how AI is creeping into every aspect of healthcare but what does that mean for medical coders and how can we better understand the language used in the codeset? Will AI take my place or will I learn with it and become an integral part of the process that uses AI to enhance my abilities?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Chronic respiratory disease is on the top 10 chronic disease list published by the National Institutes of Health (NIH). Although it is a chronic condition, it may be stable for some time and then suddenly become exacerbated and even impacted by another acute respiratory illness, such as bronchitis, RSV, or COVID-19. Understanding the nuances associated with the condition and how to properly assign ICD-10-CM codes is beneficial.
Dec 12th, 2023
Changes to COVID-19 Vaccines Strike Again
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
According to the FDA, CDC, and other alphabet soup entities, the old COVID-19 vaccines are no longer able to treat the variants experienced today so new vaccines have been given the emergency use authorization to take the place of the old vaccines. No sooner was the updated 2024 CPT codebook published when 50 of the codes in it were deleted, some of which were being newly added for 2024.
Dec 5th, 2023
2024 CPT Coding Updates...Are You Ready?
by Aimee L. Wilcox, CPMA, CCS-P, CST, MA, MT
Each year the CPT coding updates are published and coders nationwide rush to ensure they understand the impact they will have on their workflow and organization in general. For the first time in three years, changes to the Evaluation and Management (E/M) codes are minimal. However, the Medicine section, specifically the codes and guidelines for reporting COVID-19 vaccines have significant changes and unfortunately they are not reflected in that shiny, new CPT codebook you just purchased.
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