Billing and reimbursement

The fiscal year (FY) 2018 IPPS final rule included updates to payment rates and quality initiatives, as well as an ample amount of code changes and updates to ICD-10-PCS non-operating room (OR) to OR code designations.

How can we help ensure all hospital departments involved in payer contracting are on the same page and understand the terms?

Providers in some states may soon discover a big hurdle to clear when seeking to report a set of apheresis services after one MAC tightened up physician supervision requirements.

The Office of Inspector General found CMS improperly awarded an estimated $4.6 million in reimbursement for immunosuppressive drugs billed with modifier -KX (requirements specified in the medical policy have been met). The OIG also said CMS should revise guidance on modifier -KX because current guidance is confusing and contradictory. 

What are some common reasons for medical necessity denials and ways we can ensure medical necessity compliance?

In the 2018 OPPS proposed rule, CMS proposed a change to the current clinical laboratory date-of-service policies for molecular pathology tests and for Advanced Diagnostic Laboratory Tests.

In a series of press releases, CMS announced certain public health emergency policies are in effect for the parts of Texas, Louisiana, and Florida hit by Hurricanes Harvey and Irma. 

How should our facility handle patient registration after normal business hours?

Q: Our team had a recent case that involved a small midline episiotomy which extended to a second-degree laceration which was repaired with 3-0 vicryl rapide sutures. Would we code the episiotomy and repair or just the repair, and why? We are considering ICD-10-PCS code 0KQM0ZZ (Repair of the perineum muscle, open approach) and/or 0W8NXZZ (Division of the female perineum, external approach).

Q: If a patient arrives at our emergency department and the hospital's outside their insurer or third-party payer's network, how do we procede?