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HCC

Appropriate Use Criteria

Changes to Appropriate Use Criteria for Advanced Diagnostic Imaging

By Vanessa Youmans / February 5, 2020 / 0 Comments

Starting January 1, CMS began testing the condition for Appropriate Use Criteria (AUC) requiring a qualified Clinical Decision Support Mechanism (CDSM) consultation by a qualified provider for payment on Advanced Diagnostic Imaging for Medicare beneficiaries. Claims must include the ordering professional’s NPI, which CDSM tool was utilized for the consultation, and “whether the service ordered would or would not adhere to consulted AUC or whether consulted AUC was not applicable to the service ordered” (Medicine Learning Network, 2018). The program will be fully implemented by January 1, 2021.

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ProFee Coding

Weighing the Differences and Similarities of ProFee and Facility Coding

By Vanessa Youmans / January 21, 2020 / 0 Comments

Physician group acquisition by major health systems remains a common trend in the industry. One survey of over 8,700 physicians indicates that only 31% of physicians surveyed identify as an independent practice owner or partner as of 2018. This is down from 48.5% in 2012, a whopping 35% decrease in independently owned practices in only 6 years (Merritt Hawkins, 2018). In these acquisitions, the question remains: Who will manage the physician group?

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M.E.A.T. Criteria

HCC Chronic Conditions and M.E.A.T. Criteria

By Karen Youmans / January 13, 2020 / 0 Comments

As a follow-up to our previous articles “The HCC Coding Specialist: Benefiting payers, providers, and patients” and “HCC Medicare Advantage background and overview,” we now review HCC chronic conditions and the M.E.A.T. documentation criteria.

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ICD-11

ICD-11 Overview

By Karen Youmans / January 6, 2020 / 0 Comments

The World Health Organization (WHO) recently released the 11th edition of the International Classification of Diseases (ICD-11). This release was presented at the World Health Assembly on May 25, 2019 for adoption by member states, and will come into effect on January 1, 2022. However, note that it is still unknown when ICD-11 will be ready for implementation in the United States.

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Medicare Advantage

Medicare Advantage Insurers Use Reviews to Get Higher Payments

By YES HIM Consulting / December 20, 2019 / 0 Comments

An investigation by the Office of Inspector General (OIG) revealed Medicare Advantage insurers might be overstating patients’ diagnoses without the proper documentation to receive larger payments. Based on the 2016 Medicare Advantage encounter data analyzed by the OIG, insurers were able to get an extra $6.7 billion in payments in 2017.

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HCC risk adjustment

HCC Medicare Advantage background and overview

By Karen Youmans / October 16, 2019 / 0 Comments

As a follow-up to our previous article “The HCC Coding Specialist: Benefiting payers, providers, and patients” we now delve in deeper to the background and overview of HCC risk adjustment for the Medicare Advantage Program.

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