Do I Still Need Progress Reports?

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By:Jacqueline Thelian, CPC, CPC-I, CHCA

As per the Centers for Medicare and Medicaid Services (CMS) effective for dates of service on and after January 1, 2019 the reporting of HCPCS G Codes for Functional reporting and the severity modifiers are no longer required. 

This change had no impact on the requirement to document Progress Reports.  The CMS Local Coverage Determinations (LCD) state “Progress reports shall be written by a clinician at least once every 10 treatment days. A progress report is not a separately billable service.” 

It is important to keep in mind progress reports are oftentimes the  key document in physical therapy audits to provide the medical necessity for the services rendered. 

For further information  please go to the following CMS sites:  CMS All Fee For Services Providers Page https://www.cms.gov/Center/Provider-Type/all-fee-for-service-providers-center.html

The Clock is Ticking for Quality Payment Program (QPP) Data Submission

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By:Jacqueline Thelian, CPC, CPC-I, CHCA

It’s that time again. The QPP data submission site is open now until April 2, 2019, 8pm.

If you are part of an Accountable Care Organization (ACO) or Alternative Payment Model (APM) who will submit quality measures on your behalf remember you are most likely  responsible to report your Promoting Interoperability.  It is advised to check with you ACO/APM, many of which encourage the providers/group to report this on their own.

For an eligible clinicians or groups reporting on their own or to report their Promoting Interoperability, go to the QPP Data Submission System https://qpp.cms.gov/login and you can login using either your Enterprise Identity Management (EIDM) credentials or the new HCQIS Authorization Roles and Profile (HARP).

It is recommended you sign in during the submission period which will allow you to review the entered data before the final submission.

If you are an EC reporting via administrative claims, your reporting was included in all your claims.


Home Visits, Now on Cruise Ships and Campgrounds!

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By:Jacqueline Thelian, CPC, CPC-I, CHCA

(99347 – 99350)

Yes, it is true CMS  updated the definition of home to include, temporary lodging and short term accommodations. The change includes places such as, hotels, hostels, campgrounds, and cruise ships.

Other changes to the home visit include:

  • Only requiring documentation of an interval history since the previous visit

  • Eliminating requirements to re-document information from practice staff or patient

  • Removing the need to justify home visits in place of office visits

2019 Proposed E/M Changes

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By: Lorna Simons, CPC
Medco Consultants, Inc

E/M Changes Proposed in the Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2019

There are a lot of concerning changes proposed to Outpatient Evaluation and Management (E/M) services currently being assessed by Medicare. While a long-awaited change is currently being considered for the documentation guidelines, the Revisions to Payment Policies under the Medicare Physician Fee Schedule, Quality Payment Program and Other Revisions to Part B for CY 2019 is also considering flat rate fees for all outpatient new and established evaluation and management services. Additionally, proposed changes are being considered for the creation of separate codes to report Podiatric E/M services. These changes are all linked.

As per the proposed rules: “the current set of 10 CPT codes for new and established office-based and outpatient E/M visits and their respective payment rates no longer appropriately reflect the complete range of services and resource costs associated with furnishing E/M services to all patients across the different physician specialties, and that documenting these services using the current guidelines has become burdensome and out of step with the current practice of medicine…To alleviate the effects and mitigate the burden associated with continued use of the outdated CPT code set, we are proposing to simplify the office-based and  outpatient E/M payment rates and documentation requirements, and create new add-on codes to  better capture the differential resources involved in furnishing certain types of E/M visits.”(p136-137)

The proposed rates are as follows:

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The specialties that will be most negatively affected by these changes are Rheumatology, Neurology, Hematology/Oncology and Endocrinology.

In regard to podiatry services, the proposed rules indicate that a majority of podiatric E/M services are level 2 or 3 services and that the consolidation payment rates for level 2-5 services does not accurately reflect the resources used to perform an E/M service in the podiatric setting. If the specialty were to be included podiatry would receive the greatest benefit out of all the specialties, approximately a 12% increase in payment. Rather than include the specialty in this consolidation of E/M payment, CMS is proposing the creation of two (2) new HCPCS codes: GPD0X for New patients and GPD1X for Established patients.

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The proposed regulations were published on July 27, 2018. Luckily these are just proposed changes and affected providers are still currently able to comment on these proposals until September 10, 2018. 

Am I Using the Right Type of Service (TOS) Indicator for Mammography Coding?


By: Lorna Simons, CPC
Medco Consultants, Inc

Effective on January 1, 2018 CPT code 77067 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed was instructed to be used for Medicare patients replacing HCPCS G0202 Screening mammography, bilateral (2-view study of each breast), including computer-aided detection (CAD) when performed. 

Medicare Administrative Contractors (MACs) were instructed to use the same payment methodologies with CPT code 77067 as they did for HCPCS code G0202. As such, the Type of Service (TOS) indicator has remained “1”. Using TOS indicator 1 will allow the screening Mammography claims to be billed out without the referring physician information on the claim form.

It is important to note that if the service is diagnostic, it would be appropriate to use TOS indicator 4. In cases where the services are diagnostic the referring provider information is necessary for the claim form.



  • Change in Type of Service (TOS) for Current Procedural Terminology (CPT) Code 77067, MLN Matters Number: MM10607
  • 2018 Current Procedural Terminology (CPT Manual)


Are You Ready for The New Medicare Beneficiary Cards?

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By: Lorna Simons, CPC
Medco Consultants, Inc

Medicare will begin mailing out the new Medicare cards to beneficiaries in April 2018. The cards are expected to be sent out in seven waves depending on the state. Below we’ve included Medicare’s mailing strategy for when your practice should expect to begin seeing patients with the new beneficiary cards.

You should begin advising your patient’s and/or their caregivers to expect their new cards between April 2018 and April 2019.  The cards will be sent to the address on file at the Social Security Administration. When notifying the patient’s have them verify their address with the SSA and ask them to bring them to your office for your staff to update the patient’s demographics in your system to ensure there are no missteps in receiving the new cards. 

During the transition period, between April 2018 and December 2019, you will be able to use both the HICNs (Health Insurance Claim Number) and/or the new MBIs (Medicare Beneficiary Identifier) for billing and corresponding with Medicare. Starting January 1, 2020, only the MBI will be accepted. 




2018 ICD-10-CM Hypertension and Heart Disease


By: Lorna Simons, CPC
Medco Consultants, Inc

The most delightful change to the ICD-10-CM guidelines (in my opinion) is that they made coding hypertension with heart disease easier. The new guideline presumes a causal relationship between the heart disease (I50.-; I51.4-I51.9) and hypertension (I10).

In previous years, the guidelines for hypertension indicated the use of combination codes for hypertension and heart disease when the causal relationship was stated or implied. Without the causal relationship the conditions would be coded separately. This meant that the documentation requirements for using the combination codes had to use specific language to indicate or imply the relationship. It also meant that billers would need to query the providers to ensure the proper codes were used.

The new guideline eases the documentation requirements for specific language. The combination codes should be used unless the providers documentation clearly indicates that they are separate. 

For example, it would be appropriate to code I11.9 Hypertensive heart disease without heart failure and I51.5 Myocardial degeneration for a patient with documented hypertension and a history of Myocardial degeneration based on the new guideline. Previously, the patient note would have had to indicate the hypertension was due to myocardial degeneration. 



  • 2018 International Classification of Diseases, 10th revision, clinical modification (ICD-10-CM) Guidelines Section I.C.9.a. Hypertension

  • 2017 International Classification of Diseases, 10th revision, clinical modification (ICD-10-CM) Guidelines Section I.C.9.a. Hypertension


Why Is Medicare Denying My Claims for Mammography and Breast Biopsies?


By:Jacqueline Thelian, CPC, CPC-I, CHCA

When Medicare updated their systems with the updates to mammography and breast biopsy policies some ICD-10-CM codes were inadvertently left out. 

The omitted new codes are N63.11-N63.14, N63.21-N63.24, N63.31, N63.32, N63.41, and N63.42, which will replace the truncated ICD-10 diagnosis N63.

The Centers for Medicare & Medicaid Services (CMS) will correct the policies with its next update, which is scheduled for April 1. But CMS did not require its Medicare contractors to reprocess the denied claims. 

CMS has instructed MACs to adjust any claims brought to their attention that were processed in error for any of the NCDs included in CR 10318. These adjustments will not take place until after April 2, 2018 unless otherwise noted.

National Government Services (NGS) has already updated their system and will reprocess claims upon the providers request.


  • CMS Transmittal 2005 ICD-10-CM and other Coding Revisions to National Coverage Determinations (NCDs)