Laboratory Fee Schedule Takes A Big Hit In 2018


By:Jacqueline Thelian, CPC, CPC-I, CHCA & Lorna Simons, CPC
Medco Consultants, Inc

Your practice may see a marked decrease in Medicare reimbursements for certain laboratory services in 2018. As a part of the Protecting Access to Medicare Act (PAMA) of 2014, CMS has revised the laboratory fee schedule to make the rates more equivalent to private insurance plans which have lower rates. 

Many of the common laboratory tests performed in physicians’ practices such as CBC (85025) Comprehensive Metabolic Panel (80053) Prothrombin (85610) and hundreds of others are set to for a 10% payment reduction and an additional 115 codes will see a 9% reduction in reimbursement.

The lab fee schedule will affect all practices submitting claims for Medicare laboratory services. Many physicians running labs are doing so on a very slim profit margin and the reduction will bring the sustainability of in office laboratory testing in question. It is important to note, not all laboratory reimbursements will be decreased. In some cases, the fee schedule has gone up. 

For a sampling of affected services please see the below table:

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Therapy Caps Are Going Up For 2018


By: Lorna Simons, CPC
Medco Consultants, Inc

Great news! The therapy cap will be going up for 2018. Announced on November 9, 2017, the therapy cap will be going from $1,980 to $2,010. 

Therapy caps were created under Section 4541 of the Balanced Budget Act to financially limit the Outpatient Therapy services provided to Medicare beneficiaries. Speech Language Pathology (SLP) and Physical Therapy share a cap while Occupational Therapy has separate cap. 

It is important to remember, when coding therapy services, to append the appropriate modifier to the services so that it is applied to the right cap. Certain CPT codes considered “always therapy” codes, as well as any service performed in a Therapist in Private Practice (TPP) setting, should be appended with the appropriate modifier. 

  • Modifier GN- Services delivered under an outpatient speech language pathology plan of care
  • Modifier GO- Services delivered under an outpatient occupational therapy plan of care
  • Modifier GP- Services delivered under an outpatient physical therapy plan of care

Exceptions can be made to the therapy caps based on the patient and medical necessity, however, it is important to note that providers who routinely go beyond the therapy caps can be subject to post-payment reviews. While MACRA has eliminated the manual medical review requirements for services over therapy threshold ($3,700), providers with a high patient population receiving therapy beyond the cap threshold may be selected for review.


Opioid Use, Abuse and Dependence in ICD-10-CM


By: Lorna Simons, CPC
Medco Consultants, Inc

It is seldom that we go a week without seeing a new opioid linked headline in the news. As medical coders and healthcare professionals it is important to understand the nuances of coding for opioid use (prescribed or recreational), abuse and dependence. Though three separate sections of the ICD-10-CM book can be used to code patients using opioids (Chapter 21 Factors influencing health status and contact with health services (Z00-Z99); Chapter 5 Mental, Behavioral and Neurodevelopmental disorders (F01 – F99) and; Chapter 19: Injury, poisoning, and certain other consequences of external causes (S00-T88)), we will be focusing on the difference between prescribed and recreational use abuse and dependence (chapters 21 and 5).

Prescription use of opioids is identified in Chapter 21 of the ICD-10-CM manual. When a patient is receiving prophylactic prescription maintenance for a condition using an opioid it should be documented and coded with Z79.891 Long term (current) use of opiate analgesic. Do not use this code for patients who have addiction or are seeking treatment for addiction. The Chapter 21 Guidelines state: “This subcategory is not for use of medications for detoxification or maintenance programs to prevent withdrawal symptoms in patients with drug dependence (e.g., methadone maintenance for opiate dependence). Assign the appropriate code for the drug dependence instead.”

The codes for opioid related disorders are found in Chapter 5 under category F11. The term “use” in Chapter 5 can mean non-prescription (recreational) use or any use not documented as abuse or dependence. The distinction between use, abuse and dependence is based on clinical evaluation and documentation. As per the ICD-10-CM guidelines for coding substances use, abuse and dependence, “only one code should be assigned to identify the pattern of use based on the following hierarchy:

  • If both use and abuse are documented, assign only the code for abuse 
  • If both abuse and dependence are documented, assign only the code for dependence 
  • If use, abuse and dependence are all documented, assign only the code for dependence 
  • If both use and dependence are documented, assign only the code for dependence.”

A patient with a history of opioid abuse or dependence should be coded with the appropriate remission code (F11.11 Opioid abuse, in remission or F11.21 Opioid dependence, in remission). ICD-10-CM does not include a code for history of opioid use. 


  • ICD-10-CM Coding Guidelines Section C.5. Psychoactive Substance Use, Abuse and Dependence

  • ICD-10-CM Coding Guidelines Section C.21. Factors influencing health status and contact with health services (Z00-Z99)

  • ICD-10-CM Coding Guidelines Section C.19.  Injury, poisoning, and certain other consequences of external causes (S00-T88)

Medco’s Certified Professional Coding Course

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By: Lorna Simons, CPC
Medco Consultants, Inc

Twice a year Medco holds a Certified Professional Coding (CPC) Course in which we teach the American Academy of Professional Coders (AAPC) curriculum for outpatient medical coding. At the end of the course, which has grown over the years to 16 weeks, we proctor the AAPC’s CPC exam privately for our students. But what does this mean?

There are many different types of certificates and certifications that can be achieved in the medical coding field. The AAPC is one of the largest nationally recognized certifying organizations. They offer many different certifications including those in specialty specific coding, however, before getting the other certifications you must first pass the CPC Exam. You may say the CPC is like a gateway certification.

Using the AAPC’s curriculum with real life examples allows us to prepare our students for the exam as well as day to day coding. The examination is multiple choice using the International Classification of Disease, 10th Revision, Clinical Modification (ICD-10-CM), Current Procedural Terminology (CPT) and Healthcare Common Procedural Classification System (HCPCS) manuals. The test is designed to determine if the coder understands how to navigate the manuals to code a variety of questions and scenarios.

While the AAPC does not require any specified length of training to sit for the CPC exam, the examinee must have a minimum of 80 hours of classroom learning to waive a year of coding experience. The examinee must have at least 2 years of experience to earn a CPC. Without 2 years of experience, the examinee will be given the CPC-A (apprentice) designation upon passing the CPC exam. All classroom hours after the initial 80 are not applied to the years of experience. 160 hours of classroom learning will NOT earn you 2 years of experience. 

Since the course began in 2005, Medco has used its knowledge and understanding of coding and compliance concerns to help students reach their potential. Our course instructors are all certified through the AAPC and currently work in the coding and compliance field. 

Twice a year Medco meets and educates a new group of coders using curriculum specifically designed to help them pass a test that will lead to many different opportunities. The classes real life examples help navigate day to day coding and the length of the course will waive a year of coding experience. 

How will the new Medicare ID numbers impact my practice?

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By: Jacqueline Thelian, CPC, CPC-I, CHCA
Medco Consultants, Inc

The new Medicare Beneficiary ID (MBI) numbers will be 11 alphanumeric characters. Starting in April 2018, new beneficiary cards and numbers will be issued. All Medicare cards are expected to be replaced by April 2019. During the transition period healthcare providers will be able to use either patient identifier (HICN or MBI) when submitting claims until December 31, 2019.

The new ID numbers require your practice management systems are updated with the new numbers. Keeping in mind your system will have to be able to identify and handle dual MBI numbers until all claims are paid. Additional concerns occur when a practice submits a claim with an old MBI number and CMS sends back the electronic remittance with the new MBI number. Some practice management systems may not be able to identify the patient.

The biggest challenge will be secondary payers. CMS will notify the secondary payers; however, it is up to the secondary payer to update their systems. 

The best way to prepare is to inform and train your front desk staff of the upcoming change and work with your practice management vendor and IT consultant to enlist their aid for a smooth transition.

CMS Signature Requirements

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By: Lorna Simons, CPC
Medco Consultants, Inc

How do you know if the signature on your health records is valid? Before working in medical coding, I had assumed that all signatures, even the most ill-defined were valid. We all know too well the jokes about doctor’s handwriting.  However, the Center’s for Medicare and Medicaid Services (CMS) has certain requirements for physician signatures to be valid. 

Signatures can be either handwritten or electronic. Signature stamps are only permissible if the provider suffers from a physical disability and can prove that they are incapable of signing a patient note due to disability. 

Handwritten signatures must be legible. If the signature is not legible, it should be accompanied by the provider’s name either printed, typed, or on the letterhead. Providers may have a signature log on file with their name typed and signed to show that the signature is their own or attest their signature if required for purposes of review.

Electronic signatures must protect against modification and have certain administrative safeguards. Once the note is signed with the electronic signature, the note should be locked and any changes and updates would have to be made with addendums. If the system does not protect the notes against modification, then the signature is invalid. Electronic signatures can be digitized (the provider’s signature in an electronic image) or statements indicating the note was signed electronically. The signature usually has a date and time stamp. It is important to note that as per the guidance provided by Palmetto GBA, “Indication that a document has been ‘signed but not read’ is not acceptable…”

Its important to remember that signatures are required to authenticate treatment/surgical notes, procedures and orders for diagnostic testing and labs. The signature must be by the treating or ordering healthcare provider.


New NCCI Edits for Orthopedic Codes

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By: Jacqueline Thelian, CPC, CPC-I, CHCA
Medco Consultants, Inc

As you know the National Correct Coding Initiative (NCCI) edits define pairs of CPT/HCPCS codes that should not be reported together for a variety of reasons. 

The latest version of NCCI edits V23.3 effective October 1, 2017 targets shoulder procedures. Now CCI will bundle shoulder release code 23020 into arthroplasty 23470-23474 codes. This means it would be inappropriate to report the two codes for the same shoulder. You may however, unbundle and report them on the opposite shoulders.

Additionally, Chapter 4 of the NCCI edits state, “When a fracture or dislocation is repaired, only one fracture/dislocation repair code may be reported. Closed repair codes, percutaneous repair codes, and open repair codes for the same anatomic site are mutually exclusive of one another, and only one of these codes may be reported for the repair of a fracture or dislocation at an anatomic site.”

Once again separate billing would only be appropriate when these services are provided on opposite shoulders. 


Targeted Probe and Educate (TPE)

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By: Lorna Simons, CPC
Medco Consultants, Inc

Have you ever been caught in the avalanche of paperwork and uncertainty that is entailed with a Medicare appeal? Medicare audits are never a fun topic to discuss. They can at times be a long, drawn out processes. In an effort to “reduce appeals, decrease provider burden and improve the medical review and education process,” Medicare has expanded the Targeted Probe and Educate (TPE) pilot program to all of their Medicare Administrative Contractors (MACs) for Part A, B, HHH and DME.

How will this reduce the number of appeals? 
The providers/suppliers will have one (1) to three (3) pre- or post-payment rounds of review. After or during each review, the healthcare provider /supplier will be educated based on MACs findings. The educational sessions are offered via webinar or telephone conference by a nurse reviewer. Other educational methods are available if necessary. If the healthcare provider/supplier is found to be non-compliant with Medicare, they will be reviewed again. 
Only when the provider/supplier is found to be non-compliant following the third review, will they be referred to the Centers of Medicare and Medicaid services (CMS) for additional action. These actions include “extrapolation, referral to Zone Program Integrity Contractor(ZPIC) or Unified Program Integrity Contractor (UPIC), referral to the RAC or 100% pre-pay review,” etc. (i.e. audit).

How will this decrease provider/supplier burden?
The MACs will be reviewing limited samples of 20 to 40 claims per review round. This will decrease the amount of documentation being sent out and ease the economic burden of being on 100% pre-payment review for providers/suppliers with high Medicare patient populations. After each round of audit and education, non-compliant providers/suppliers will have a minimum of 45 days to improve documentation and become compliant before the next round commences.