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the current practice of medicine…To alleviate the effects and mitigate the burden associated with continued use of the outdated CPT code set, we are proposing to simplify the office-based and  outpatient E/M payment rates and documentation requirements, and create new add-on codes to 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)

KX Modifier Temporary Fix


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

Did CMS reinstate the use of the KX Modifier for therapy claims? Yes and No. CMS implemented a temporary fix.

Despite Congressional failure to remove the cap exception, on January 28, 2018 CMS announced they will start to pay claims submitted with the KX modifier (Requirements specified in the medical policy have been met).

Starting January 25, 2018, CMS will immediately release for processing held therapy claims with the KX modifier with dates of receipt beginning from January 1-10, 2018.  Then, starting January 31, 2018, CMS will release for processing the held claims one day at a time based on the date the claim was received, i.e., on a first-in, first-out basis.

At the same time, CMS will hold all newly received therapy claims with the KX modifier and implement a “rolling hold” of 20 days of claims to help minimize the number of claims requiring reprocessing and minimize the impact on beneficiaries if legislation regarding therapy caps is enacted.

CMS did not indicate if this temporary fix will continue until Congress can get the cap extension reinstated. 

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

No Therapy Cap Exceptions for 2018

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

Beginning January 1, 2018, the cap on physical therapy services has a slight increase to $2,010.00.  That’s the good news.

The bad news, the “exception process” which would allow the continuation of PT services up to $3,700.00 with the use of the “KX” modifier (Requirements specified in the medical policy have been met) is no longer applicable. 

Additionally, the manual review process for claims that would exceed the $3,700.00 is also no longer a valid option.

The Final Rule which put the end to the exception process states, “Without a therapy cap exceptions process, the statutory limitation requires that beneficiaries become financially liable for 100% of expenses they incur for services that exceed the therapy caps” The rules goes on to state, “the therapy caps will be applicable without any further medical review, and any use of the “KX” modifier on claims for these services by providers of outpatient therapy will have no effect.” In short, without the renewal of the exception process:


  • CMS will deny reimbursement of any claims that exceed the current therapy cap of $2,010.00
  • Medicare beneficiaries will be responsible for claims over the cap amount of $2,010.00
  • The KX modifier for Physical Therapy claims will have no impact on the claims

So, what can you? Providers can issue Advanced Beneficiary Notices (ABNs). The ABN is a notice of non-coverage which advises the Medicare beneficiaries of non-coverage and their financial responsibility for therapy over the cap. Click on the link below to brush up on how to complete the ABN.  


New CPT Codes for INR Testing Reimbursed by Medicare

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

CPT 2018 introduces new codes for home and outpatient International Normalized Ratio (INR) services. The new codes are more user friendly than the former INR CPT codes 99363 and 99364 which were deleted for 2018. 

The new codes include the ordering, review, and interpretation of new INR test result(s), patient instructions, and dosage adjustments as needed. 

An Evaluation & Management (E/M) code may be reported in addition to the new codes as long as the E/M is significant and separately identifiable. Additionally, the codes do not include the provision of the test materials and equipment which is reported separately.
Unlike the former INR codes which required physician review the new codes may be performed by the clinical staff under the direction of a physician or qualified healthcare professional.

The new codes are:
93792 Patient/caregiver training for initiation of home international normalized ratio (INR) monitoring under the direction of a physician or other qualified health care professional, face-to-face, including use and care of the INR monitor, obtaining blood sample, instructions for reporting home INR test results, and documentation of patient's/caregiver’s ability to perform testing and report results

93793 Anticoagulant management for a patient taking warfarin, must include review and interpretation of a new home, office, or lab international normalized ratio (INR) test result, patient instructions, dosage adjustment (as needed), and scheduling of additional test(s), when performed

The best news is saved for last as CMS recognizes and reimburses for the new codes. The national reimbursement rate for CPT code 93792 is $55.06 and CPT code 93793 reimburses nationally at $12.24. You can search for reimbursement rates for your locality on the CMS Physician Fee Schedule Look Up Tool by going to: 



  • Current Procedural Terminology (CPT) 2018

  • CMS Physician Fee Schedule Look Up Tool