Understanding Medicare’s Outpatient Mental Health Treatment Limitation

By law, Medicare payment for outpatient mental health services is limited to 62.5 percent of covered expenses incurred in any calendar year in connection with the treatment of a mental, psychoneurotic, or personality disorder for an individual who is not an inpatient of a hospital at the time the expenses are incurred. Unfortunately, when you […]

Ostomy Documentation Tips

For the 2018 reporting period, insufficient documentation accounted for 81.6 percent of improper payments for ostomy supplies. Additional types of errors for ostomy supply claims in the 2018 reporting period were no documentation (2.3 percent) and medical necessity (1.9 percent). Medical records must contain adequate, clear documentation that supports the medical necessity of the amount […]

Critical Care Services and Medical Necessity

Critical care services must be medically necessary and reasonable. Services provided that do not meet critical care services or services provided for a patient who is not critically ill or injured in accordance with the above definitions and criteria but who happens to be in critical care, intensive care, or other specialized care units should […]

Modifier 50 Fact Sheet

Modifier 50 applies to bilateral procedures performed on both sides of the body during the same operative session. When a procedure is identified by the terminology as bilateral or unilateral, the 50 modifiers are not reported. If a procedure is authorized for the 150 percent payment adjustment for bilateral procedures (payment policy indicator 1), […]

Moderate (Conscious) Sedation Coding Guidelines

Moderate Sedation Coding Guidelines To ensure accurate billing, it’s essential to follow Sedation Coding Guidelines, which specify the proper codes for different sedation levels and procedures. By adhering to these challenges, medical practices can avoid coding errors and ensure appropriate reimbursement. Moderate sedation is a service provided by the physician or other qualified healthcare professional […]

Global Surgery and Billing Guidelines

The global surgical package, also called global surgery, includes all the necessary services normally furnished by a surgeon before, during, and after a procedure. Medicare payment for a surgical procedure includes the preoperative, intra-operative, and post-operative services routinely performed by the surgeon or by members of the same group with the same specialty. Physicians in the […]

Changes in RT and LT Modifier Usage

The Durable Medical Equipment Medicare Administrative Contractors (DME MAC) are changing the requirement that medical coders to use the RT and LT modifier for certain HCPCS codes, and that the modifiers be used when billing two of the same item or accessory on the same date of service and the items are being used bilaterally. […]

Basic Guidelines for Inhalation Treatment Billing

There are many services and products that may be billed when a patient presents with chronic asthma or other serious respiratory conditions or acute exacerbation of related symptoms. Physicians must capture all pertinent information in their documentation and, in turn, coders (or those who validate pre-coded electronic health record charges) must account for all related […]

Basic Guidelines for Billing Nebulizers

Nebulizers can be covered if the member’s ability to breathe is severely impaired. Lung diseases such as chronic obstructive pulmonary disease (COPD) and asthma are characterized by airflow limitation that may be partially or completely reversible. Pharmacologic treatment with bronchodilators is used to prevent and/or control daily symptoms that may cause disability for persons with […]

Medicare Advance Beneficiary Notice – 5 Tips for Reimbursement Success

An Advance Beneficiary Notice (ABN) is a waiver of responsibility that is issued to a patient to make sure you receive payment for services and items that are usually covered by Medicare but are not expected to be covered on this occasion. When completed properly, you should be able to recover the cost of the […]

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