BC ADVANTAGE - January/February 2025 / Issue 20.1

Providing resources for medical practices and the people behind them

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An Overview of the

2025 CPT

January / February 2025 | Issue 20.1

Telemedicine Guidelines

A Practical Guide for Enhancing Efficiency Across Clinical Administration and HIM Services HIPAA and Cyber Items to Keep on Your Radar in 2025 Healthcare Awareness Spotlight: January Is Cervical Cancer Awareness Month Possible Loss of Screening Coverage Will Impact Radiology Practices

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CONTENTS MAGAZINES | CEUS | WEBINARS

JANUARY / FEBRUARY 2025 - ISSUE 20.1

An Overview of the

2025 CPT

Telemedicine Guidelines

OTHERS

FEATURES 10. Possible Loss of Screening Coverage Will Impact Radiology Practices 12. A Practical Guide for Enhancing Efficiency Across Clinical Administration and HIM Services 16. How Medical Coding Drives Value-Based Care and Better Patient Outcomes 20. Financing Solutions for a Healthier System: Aligning Patient Financial Health With Healthcare Stability

32. HIPAA and Cyber Items to Keep on Your Radar in 2025 36. Rate Increases in Stop Loss or Pie in the Sky? 40. Medicare Advantage Plans: Coding Challenges and Best Practices 44. Monthly Spotlight on Fraud, Waste, and Abuse 48. The Three Essentials for Success

24. Healthcare Awareness Spotlight: January Is Cervical Cancer Awareness Month 4

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6. News / Updates 50. Reviews Electronic Health Records: An Audit and Internal Control Guide AI in Healthcare From Basics to Breakthroughs ERISA Principles

EXPERT Contributors this issue Sandy Coffta is Vice President of Client Services at Healthcare Administrative Partners. Ms. Coffta has over 17 years of experience in client relationship management, including reimbursement analysis, workflow optimization, and compliance education. www.hapusa.com Amber Darst, CPC, is a Solutions Manager in the Practice and Revenue Cycle Management Department for Managed Outsource Solutions. She brings several years of healthcare experience to the company, specializing in both Medicaid and dental billing and insurance verification services. www.managedoutsource.com Megan DeVoe is Vice President of Coding and CDI Services; and Lina Sanchez, MD, MPH, CCDS, CCS, is Director of Clinical Services with AGS Health. At AGS Health, they help you streamline your revenue cycle through intelligent automation and global services so you’re free to invest in your organization and its mission.

AGSHealth.com Joe Dore is president of USBenefits Insurance Services.

Joe is an Underwriting and Marketing executive with over thirty years of managerial experience in the insurance industry. www.usbstoploss.com Betty A Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, is a nationally recognized healthcare consultant and speaker. She is an expert auditor and loves to help practices stay compliant and profitable.

Betty states, “Physicians work hard for their practices and they should be paid properly for what they do.” chcs.consulting/ Dave Jakielo is an International Speaker, Consultant, Executive Coach, and Author, and is President of Seminars & Consulting. Dave has been helping companies grow and improve their profitability for over four decades. Sign up for his FREE weekly Success Tips at www.Davespeaks.

com. Dave can be reached via email Dave@Davespeaks. com; phone 412-921-0976. Davespeaks.com Loralee Kapp is a Solutions Manager at Managed Outsource Solutions, holding a degree in Health Information Management and Technologies. With over five years of experience in medical coding and health information management, she has been a valued member of the MOS team since 2021. www.managedoutsource. com Meredith Kirchner is a seasoned healthcare operations leader with over 20 years of experience. She currently serves as the Chief Operating Officer at Curae, where she focuses on improving operational efficiency and client satisfaction through innovative financial solutions for multi-hospital health systems. Meredith has a strong background in healthcare consulting and technology, having held senior roles at Patientco and Ernst & Young. www.curae.com Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist at SP Collaborative, LLC. Sonal has over 13 years of experience understanding the art of business medicine. She is a nationally recognized thought-leader, speaker, author, creator, and consultant. https://spcollaborative.net/ Rachel V. Rose, JD, MBA (Houston, Texas), is a disciplined, empathetic, and tenacious attorney advocating for and winning desired legal outcomes for national and international clients. Ms. Rose’s practice includes compliance, transactional, and litigation matters primarily related to healthcare, cybersecurity, securities, the False Claims Act, and Dodd-Frank. She is also affiliated with Baylor College of Medicine where she teaches bioethics. www.rvrose.com

BECOME PART OF SOMETHING BIGGER We are always interested in hearing from any industry experts who would like to get published in our national magazine.

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NEWS Survey Uncovers Widespread Medical Billing Errors and Coverage Denials Among Insured Americans A recent survey by the Commonwealth Fund highlights significant issues faced by insured, working-age adults in the U.S. regarding medical billing errors and coverage denials. The survey revealed that nearly half (45%) of insured adults received a bill or copayment for services they believed should have been covered by their insurance. Additionally, 17% of respondents reported being denied coverage for a doctor-recommended service.

These billing problems and denials often have a negative impact on health outcomes. Nearly 60% of individuals who had coverage denied reported delayed care, and almost half of them saw their health conditions worsen as a result.

Despite the prevalence of these issues, many Americans are unaware of their rights to dispute medical billing errors or coverage denials. The survey found that less than half of those who experienced such issues actually took action to challenge them.

Over half (54%) of those who did not dispute the issues were unaware they had the right to do so. This lack of awareness was most pronounced among younger adults (ages 19-34), individuals with low to moderate incomes, and Hispanic respondents. Many young adults were also unsure of whom to contact for help with billing errors.

For those who did challenge their bills or denied coverage, success rates were relatively high. Half of those who disputed coverage denials were able to have some or all of the denied services approved. Additionally, over one-third (38%) of those who contested billing errors had their charges reduced or eliminated.

Beneficiaries of Medicare and Medicaid reported even higher success rates. Among Medicare recipients, 61% successfully reduced or eliminated their bills after disputing them, while 46% of Medicaid recipients achieved similar results.

The findings underscore the need for policy changes to enhance consumer protections, such as increased monitoring of claim denials, greater accountability for insurers, and improved public awareness of appeal rights.

The Commonwealth Fund’s Health Care Affordability Survey was

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conducted between April and July 2023. The survey involved telephone and online interviews with a random sample of 7,873 adults across the U.S., including 5,602 insured adults under the age of sixty-five.

For more details, visit Commonwealth Fund.

Mainstay Medical Announces New ICD-10 Diagnosis Code for Multifidus Dysfunction Mainstay Medical has announced that the United States Centers for Disease Control and Prevention (CDC) has officially recognized a new ICD-10-CM diagnosis code for multifidus dysfunction in the lower back. Effective October 1, 2024, the new code, M62.85 – Dysfunction of the Multifidus Muscles, Lumbar Region, will help clinicians better identify and diagnose this condition.

Multifidus dysfunction occurs when an acute low back injury triggers a reduction in the neural activation of the multifidus muscle. This decreased activity of the multifidus muscle, a primary stabilizer of the lumbar spine, leads to joint instability and excessive strain, contributing to the persistence of chronic low back pain (CLBP). The ReActiv8® Restorative Neurostimulation™ system is designed to deliver electrical stimulation to the nerves controlling the multifidus muscle, helping restore its function and promote recovery from CLBP. ReActiv8 is the only FDA-approved treatment specifically for intractable CLBP associated with multifidus muscle dysfunction.

“This new ICD-10 code highlights the importance of multifidus muscle dysfunction as a key contributor to CLBP and provides a more accurate way for healthcare providers to diagnose this condition,” said Jason Hannon, CEO of Mainstay Medical. “We are excited that the CDC’s recognition of multifidus dysfunction will improve the diagnosis and management of this condition, allowing for more targeted treatments like ReActiv8.”

St. John’s University Receives $550,000 Grant to Develop AI Solution for Medical Coding and Billing St. John’s University (New York, NY) has been awarded a $550,000 grant by the U.S. National Science Foundation to develop an

artificial intelligence (AI) solution aimed at streamlining the time-intensive process of medical coding and healthcare billing.

The project will be led by Dr. Syed Ahmad Chan Bukhari, Associate Professor in the Division of Computer Science, Mathematics, and Science, and Director of Research at The Lesley H. and William L. Collins College of Professional Studies. Dr. Bukhari and his team of five to six researchers will leverage AI’s machine learning capabilities to analyze doctors’ notes, identify relevant symptoms, and automate the coding of conditions, ultimately improving the efficiency of insurance filing.

The two-year grant will support research into this emerging technology, with the goal of enabling medical offices and clinics to allocate more time to patient care and less to billing and administrative tasks. According to Dr. Bukhari, the AI-based solution would significantly reduce the burden on doctors, allowing them to focus on treating patients rather than managing coding and software-related issues.

“Doctors are trained to diagnose and treat diseases, but too often, they’re bogged down by coding tasks and software issues. This new AI system could help alleviate that burden,” said Dr. Bukhari.

AI technologies have already been applied in healthcare for patient reminders, answering queries, and disease prediction. Dr. Bukhari’s team aims to take it a step further by automating the coding process, which would allow medical offices to produce accurate diagnoses faster.

Currently, medical coders are responsible for translating doctors’ notes into standardized codes used for billing and record-keeping. This process requires identifying the key details, such as the primary reason for the visit and additional conditions treated.

Coders must then use manuals or specialized software to store this information, a process prone to human error, which can lead to long-term consequences.

“Medical coding requires immense attention to detail,” Dr. Bukhari explained. “Coders, who may have other responsibilities, often face the challenge of reading and recording detailed codes after switching from their primary tasks.”

Dr. Bukhari’s team envisions that AI can significantly speed up di-

agnosis and treatment, streamline the insurance reimbursement process, and help mitigate staffing shortages in the healthcare industry, which have been exacerbated by the COVID-19 pandemic.

As part of their research, Dr. Bukhari’s team will collaborate with medical professionals to optimize the AI system’s performance.

The team does not aim to replace medical coders but to enhance the efficiency of their work by developing a machine-based system that supports their tasks.

“Currently, the process can be fragmented, with tests, medications, and procedures being handled by different labs and departments.

This disjointed approach complicates reimbursement and delays payment. Our AI solution seeks to streamline this process and save valuable time,” Dr. Bukhari said. “Ultimately, we envision transforming the role of the medical coder into more of an auditor or fact-checker, ensuring the accuracy of the system.”

Luca Iandoli, Ph.D., Dean of the Collins College of Professional Studies, praised Dr. Bukhari’s research as a prime example of AI’s potential to innovate healthcare administration.

“This grant is a well-deserved recognition of Dr. Bukhari’s impactful research,” said Dean Iandoli. “It exemplifies how AI advancements can bring substantial improvements to the healthcare sector, benefiting a range of stakeholders, from medical professionals to patients and insurers.”

CPT® Codes for More Precise Coding Two new CPT® codes were introduced in 2024 for more precise coding of endoscopic nasal and sinus surgery for chronic rhinitis treatment using posterior nasal nerve (PNN) ablation: • 31242: Nasal/sinus endoscopy with destruction by radiofrequency ablation of the posterior nasal nerve • 31243: Nasal/sinus endoscopy with destruction by cryoablation of the posterior nasal nerve Improved Precision in Coding: These new codes allow for better documentation of procedures that use radiofrequency or cryoablation to treat chronic rhinitis, a condition with symptoms like nasal congestion, runny nose, itching, and sneezing.

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OPPS services and supplies.

Endoscopic Procedure Details: Both codes involve endoscopic visualization and destruction of the PNN region through the middle meatus of the nasal passages. The procedures are bilateral; use modifier 52 for unilateral procedures.

Exclusion of Other Codes: Coders are advised not to use these new codes with certain other procedures, such as 31231 (diagnostic nasal endoscopy) or 92511 (nasopharyngoscopy with endoscope).

Context for RF and Cryoablation: Radiofrequency (RF) ablation can also be used for other nasal procedures, such as removing hypertrophy in the inferior turbinates to improve airflow. Specific CPT® codes for these procedures are 30801 and 30802.

Coding Considerations: Physicians and coders should carefully review documentation, CPT® guidelines, and payor policies, as RF and cryotherapy for rhinitis may be considered investigational and non-covered by some commercial insurance plans.

Time to Update Your Chargemaster With the HCPCS Level II Code Changes for Fiscal Year 2025 The Centers for Medicare & Medicaid Services (CMS) has released the fiscal year (FY) 2025 update to the HCPCS Level II code set, which is used for reporting durable medical equipment, prosthetics, orthotics, and supplies (DMEPOS). This update, effective January 1, 2025, includes 169 new codes, 56 revised code descriptors, and the deletion of 63 codes. Below is an overview of the key code changes.

Durable Medical Equipment (DME) Twelve new E codes (E1803-E1829) have been added for dynamic adjustable elbow extension devices, including soft interface materials. These new codes address billing issues related to devices used for both extension and flexion.

Existing dynamic adjustable extension and flexion device codes have been revised to match the new codes.

G Codes Thirty-four new G codes (G0532-G0565) have been added, covering interprofessional assessment and management services, including telehealth, internet, and electronic health record consultations. These codes will also support advanced primary care management services.

Additionally, 33 G codes have been removed, and 26 codes have updated descriptions.

Alcohol and Drug Abuse Treatment Two new H codes have been introduced for behavioral health services related to American Indian and Alaska Native populations: • H0052: Mental health and clinical care for missing and murdered Indigenous persons • H0053: Mental health and clinical care for historical trauma J Codes

Transportation Services

Twenty-five new J codes for drugs and biologicals have been added, including codes for J7514 (Mycophenolate mofetil), an immunosuppressant for organ rejection prevention.

A new code, A9615 (Injection, pegulicianine, 1 mg), has been added to replace the discontinued code C9171 for the LUMISIGHT drug.

Medical Services

Outpatient Prospective Payment System (OPPS)

Fifty-five new M codes (M1371-M1425) have been added, along with five discontinued codes and 20 code descriptions that have been revised.

Ten codes have been deleted, including four that are replaced with new J codes for FDA-approved drugs: • C9169 - J9028 • C9170 - J9026 • C9172 - J1414 • C9290 - J0666 Additionally, 14 new C codes have been introduced for various

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Temporary Codes Twenty-one new temporary Q codes have been introduced, such as Q5139 (biosimilar injection, eculizumab-aeeb) for treating paroxysmal nocturnal hemoglobinuria. Seven Q codes have been discontinued.

Modifier Changes The JG modifier (used for reporting drugs or biologicals acquired through the 340B drug pricing program) has been discontinued.

is expected to generate an additional $2.2 billion in CY 2025 Outpatient Prospective Payment System (OPPS) payments for hospitals compared to CY 2024.

Removing Barriers for Underserved Communities

Payment Changes Two HCPCS Level II codes have been updated with new payment rates: • A4954: Neuromodulation stimulator system (mouthpiece) as part of rehabilitation therapy • E0491: Oral device for neuromuscular electrical stimulation of the tongue muscle These are some of the significant updates in the FY 2025 HCPCS Level II code set. For a full list of the updates, visit the CMS website for the complete and official documentation.

CMS Announces New Health and Safety Standards to Address Maternity Care Crisis On November 1, 2024, the Centers for Medicare & Medicaid Services (CMS) introduced new baseline health and safety standards for hospitals and critical access hospitals (CAHs) offering obstetrical services. These updates aim to improve the safety of pregnancy, childbirth, and postpartum care across the U.S. The revised standards focus on enhancing the quality assessment and performance improvement (QAPI) programs and include mandatory staff training on evidence-based maternal health practices.

“These updated requirements build on CMS’s maternity care action plan,” stated Dr. Dora Hughes, Chief Medical Officer and Director of CMS’s Center for Clinical Standards and Quality. The agency also set new emergency services readiness and transfer protocol requirements to ensure hospitals and CAHs are better prepared to manage obstetric emergencies.

Additionally, the final rule for calendar year (CY) 2025 includes a 2.9 percent increase in payment rates for hospital outpatient services and ambulatory surgery centers (ASCs). This adjustment

CMS is committed to improving health equity, especially for underserved populations, through the 2025 final rule. One major initiative is removing barriers for Medicare beneficiaries who are on bail, parole, probation, home detention, or living in halfway houses, ensuring they can access Medicare services. The rule also expands the eligibility for a special enrollment period to include those who have been recently released from incarceration or are on supervision such as bail or parole.

Furthermore, the final rule expands Medicaid coverage to enhance access to care and reduce disparities. It broadens the clinic services benefit, allowing services provided outside Indian Health Services (IHS) and Tribal clinics to be covered. States are also given the option to extend coverage to services outside behavioral health clinics and those located in rural areas. The rule also codifies a 12-month continuous eligibility requirement for children enrolled in Medicaid and the Children’s Health Insurance Program (CHIP).

Tackling the Opioid Epidemic To address the ongoing opioid crisis, the final rule includes policies aimed at reducing opioid use and increasing access to non-opioid alternatives, particularly in tribal communities. CMS is finalizing a provision from the Consolidated Appropriations Act of 2023 that offers additional payments for non-opioid drugs and medical devices proven to reduce opioid use. These treatments, which have FDA-approved indications for postoperative pain relief, will receive extra support through Medicare for Indian Health Services (IHS) and tribal hospital outpatient departments.

This policy aligns with CMS’s behavioral health objectives by helping to combat opioid overdoses while ensuring effective pain management, including high-cost treatments such as cancer care in tribal areas.

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- If you are out of state temporarily (e.g., vacation), then the Medicare rules do not apply. You should still investigate the medical-legal aspect of state licensure in that circumstance.

Compliance

Conclusion

Possible Loss of Screening Coverage Will Impact Radiology Practices

Here are some examples using a hypothetical practice located in Massachusetts: •

will help to ensure that the practice is in full compliance.

The easy availability of remote reading and the post-pandemic shift to off-site work has renewed the need for practices to be aware of the Medicare rules for reporting the place of service in order to be compliant. After-hours reading by radiologists in distant locations will produce a reimbursement rate different than the one in effect at the imaging center or hospital. In some cases, this can be used strategically to move interpretations to a location with higher reimbursement rates. The first step is to develop a system that allows the billing team to know the location of the reading services, so they can be sure to apply the rules properly.

You work and live in Massachusetts; you may read and create final reports from home.

• You work in Massachusetts but live in New Hampshire; you may create final reports from home if you have a New Hampshire license and notify the billing team of the reading address. You may create preliminary reports from home if the final is signed off from the hospital.

• You live and work in California reading exams done in Massachusetts; you must have a license in both California In and April 2020, theand Federal Medical Assistance Percentage (FMAP) Table 1: See below was increased so that states would reMassachusetts notify the billing team of your readceive extra funding for their Medicaid programs in support of the COVID-19 public health emergency. In ing address. promised Medicaid eligibility checks so that more people would be able • exchange, You work andthe live states in Massachusetts but to arepause on vacation in toThere continue to receive Medicaid getServices through pandemic.

Sandy Coffta is Vice benefits President ofto Client withthe Healthcare Cape Cod, MA; you may create final reports. is no need Administrative Partners. In this role, Sandy oversees the team to notify billing. responsible for achieving and maintaining the company’s con• You work and live in Massachusetts but are on vacation in sistently high retention and referral rates. Ms. Coffta has over 17 Florida; you may create final reports but check on the legal years of experience in client relationship management, including aspect of licensure. There is no need to notify billing. screening coverage for millions of Americans. The fedot all states went along with reimbursement analysis, workflow optimization, and compliance eral Justice Department has filed a petition requesting education. She specializes in business intelligence and reporting Some practice systems might automatically capture reading that the Supreme Court review the ruling. the FMAP increase program, but those that location, but in the end, it is the physician’s responsibility to noti- development, is a subject matter expert in radiology practice did saw significant increases in Medicaid billing, and has deep expertise in resolving payor disputes and fy the practice about their work location. Making them aware of If it is upheld, the appellate court’s decision will signifienrollment. For example, in New Jersey, there were 1.4 contract issues. www.hapusa.com these guidelines, especially as they relate to medical licensure, million people enrolled in Medicaid just before the pan- cantly impact radiology by reducing the number of people who are able to afford screening at no out-of-pocket demic hit (February 2020), and by July 2023, that figure cost. The implications extend beyond radiology to other had increased to over 2 million enrollees. Radiology specialties, as there are at least 16 services that would practices benefit when more of their patients have covPayment Locality Reporting for Radiology Professional Services no longer be required to be covered without cost-sharerage. ing by ACA insurance plans.

Patient Face to Face PC Entity vs.

Radiologist Location Type of Billing Address (Zip Code) Beginning in April 2023, states were able to resume Location TC Entity for PC eligibility checks and terminate individuals who were no Both the loss of the ACA premium subsidies and the loss Hospital IP,longer OP, ER eligible. As aDifferent Hospital Splitavailability PC/TC Hospital of screening under the ACA would cut into result, Medicaid enrollment began Hospital IP,to OP,decline; ER Different Off-Site Split PC/TC Radiologist’s Office radiologists’ flow of patients beginning no later than the

by May 2024, enrollment in New Jersey Imaging Center Different Imaging Center end of 2025 Split– PC/TC Imaging but possibly sooner.

We willCenter continue to was down 17% to 1.7 million. Many of those who lost monitor these situations as they develop. Office Medicaid coverage Different moved over to insurance plans availImaging Center Off-Site Split PC/TC Radiologist’s able from the Affordable Care Act (ACA) Exchange.

They Imaging Center Same Imaging Center Global Imaging Center were able to do so in part due to ACA premium subsiImaging Center Same Office in Same PayGlobal Imaging Center Sandy Coffta dies available under the American Rescue Plan. Those ment Locality premium subsidies are due to expire at the end of 2025.

Imaging Center Same Office in Different Split PC/TC Radiologist’s Office is Vice President of Client Services at Healthcare Payment Locality Administrative Partners.

Since the ACA contains a mandate that insurers cover preventive services, such as mammography screening, Note: “Office” includes any location where the radiologist regularly works, which could include his or her home. “Imaging Center” includes a Ms. Coffta has over 17 years of experience in client relalung cancer screening, and CT colonography, without physician office or ASC setting. A vacation hotel or other temporary location should not be reported; the address of the radiologist’s regular tionship management, including reimbursement analycost-sharing by beneficiaries, former Medicaid patients work location should be reported in Box 32. sis, workflow optimization, and compliance education. moving to the ACA plans will continue to be able to obtain these critical services. However, an appeals www.hapusa.com court decision in June 2023 has thrown ACA screening 12 BC Advantage Magazine www.billing-coding.com coverage into question and could potentially eliminate

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Compliance

A Practical Guide for Enhancing Efficiency Across Clinical Administration and HIM Services

Clinical administrative service teams face several complex challenges that impact revenues and patient care and add to clinician burden: a worsening resource shortage, disparate technologies, manual processes, and increasingly complex authorization and documentation requirements. However, the most significant issue is the competing priorities between revenue cycle management (RCM) and clinical operations – a problem worsened by complex technology and processes that lead to information silos between departments. This fragmentation increases administrative costs and hampers the productivity and effectiveness of clinical and health information management (HIM) teams.

E

ncompassing clinical documentation

utilization management (UM), prior authorizations, and clinical denials and appeals, clinical administrative services consume 15-30 percent of healthcare spending in the U.S. Simplifying these services could reclaim billions of dollars each year and lessen or eliminate widespread impacts, including: • • • •

Diversion of time and resources from patient care Delayed and lost reimbursements Static adoption of innovations and technologies Provider burnout and patient frustration

The silos created by misaligned objectives between HIM, revenue cycle, and clinical care leadership can also ham-

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per the collaborative approach required under current team-based, patient-centered care and reimbursement models.

The Core Challenges The disconnect between clinical and HIM can be deconstructed into several core challenges related to the specific activities that make up clinical administrative services.

Clinical Documentation Integrity The absence of a comprehensive CDI program – or programs hampered by the ongoing shortage of experienced professionals and increasing complexity of documentation and coding – contributes to insufficient, inaccurate, or incomplete documentation. The result is

improper coding, leading to rejected and denied claims, excessive claim rework, delayed reimbursement, surprise patient bills and write-offs, higher operational costs, and lower provider engagement and response rates. It also impacts compliance, exposing provider organizations to payor audits, fines, and clawbacks.

Moreover, organizations lacking proper CDI software are missing important centralized collaboration and tools to reduce manual processes.

Utilization Management Many UM departments struggle under the weight of staffing shortages, resource limitations, and outdated processes and technology that make staying on top of growing case volumes and increasingly complex requirements a significant challenge.

Adding to the burden is inadequate data integration, which impacts the staff’s ability to perform key tasks. When the effectiveness of UM teams is inhibited, workloads increase and turnaround times are delayed, impacting care access, quality, and outcomes and increasing costs.

Clinical Prior Authorizations Prior authorization is a hotly debated, time-consuming, and expensive manual process that physicians responding to an American Medical Association (AMA) survey blame for serious adverse events and for patients abandoning treatment, not to mention being rarely evidence-based and contributing negatively to clinical outcomes. Prior authorization is also high on the list of reasons behind claims denials, due in large part to ineffective, time-consuming processes prone to human error that lack standardization between payors and providers. Frequent rule changes by payors create additional challenges, along with payor clinical guidelines and medical necessity determinations that are often not in compliance with the latest care guidelines and regulations.

Clinical Appeals Claim denials are on the rise, leading healthcare revenue cycle and finance leaders to take a more aggressive stance on challenging denied claims. However, appeals processes are time-con-

suming, taking an additional 51 minutes of administrative time per claim (as reported in Denials Best Practice Playbook by Xtend Healthcare). Further, because 90 percent of denied claims are preventable (HFMA), it’s a problem that is more effectively addressed prior to the denial.

Peer-to-Peer Reviews Used primarily to review, clarify, or explain a plan of care and to align medical necessity and reimbursement criteria, most peerto-peer reviews must be completed within 24, 48, or 72 hours of the request to avoid denial of the claim. Proper preparation can be extensive. What’s more, the denying physician is rarely experienced in the specialty involved in the denial, although some states are addressing this issue legislatively.

Regulatory challenges and the increasingly complex nature of patient care-level decisions – which carry significant implications for providers – are also at play. For example, inpatient versus outpatient status for hospital services, such as surgical and complex radiological services and lab tests, impacts reimbursement rates and even whether the service is covered by Medicare.

Finally, poor communications and coordination between multiple providers with a common patient can cause unnecessary testing and drive higher hospital and emergency department utilization and medical costs.

Best Practices and Implementation Strategies Successfully bridging the divide between clinical operations and HIM requires adherence to best practices and establishing guidelines for change management. This approach must be patient-centered, emphasizing the importance of accurate documentation in improving patient care, clinical outcomes, and financial sustainability. It should also benefit from leadership support and alignment, with buy-in from both clinical and revenue cycle leadership, to ensure resources are allocated appropriately.

To foster communication and goal alignment, it is also important to establish a collaborative cross-functional team with

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multidisciplinary representation, including clinical staff, health information professionals, CDI specialists, and revenue cycle experts. Regular feedback loops should be established between clinical and revenue cycle teams to discuss findings, address challenges, and share best practices. This will also help foster a culture of continuous improvement, aided by regular audits, benchmarking against industry standards, and implementing feedback-driven adjustments.

Processes should be in place to keep the team current on regulatory and clinical care guideline changes and compliance requirements, as well as coding updates and medical advancements. Further, CDI initiatives should be integrated into daily clinical workflows to ensure seamless collaboration and a comprehensive understanding of documentation requirements.

Finally, an effective cross-functional team should be armed with the following to ensure success: •

•

•

Education and training for clinical staff on documentation best practices, coding guidelines, and the impact on revenue cycle outcomes.

Data-driven analytics to identify documentation gaps, coding and denial trends, and areas for improvement.

Standardized processes and tools to facilitate accurate and efficient documentation.

When engaging with an outsourced service provider – which can help overcome staffing shortages and provide access to advanced technical skills, process workflows, and technology solutions – it is important to have in place strategies to guide selection and integration into the overarching workflows. This includes a comprehensive needs assessment and vendor due diligence.

By following these best practices and strategies, provider organizations can effectively bridge the gap between revenue cycle management and clinical teams while enhancing the overall efficiency and quality of clinical administrative services like CDI programs.

Resolving the Disconnect The disconnect between RCM, HIM, and clinical services

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objectives – coupled with the harsh realities of staffing shortages, complex technologies, manual processes, increasingly complex care needs, and rising claim denials – puts clinical administrative service teams in an untenable situation that threatens provider organizations’ financial standing and ability to provide timely, high-quality, care.

Aligning priorities and integrating support services and technology into a collaborative, cross-functional team unburdened by information and communication silos and competing objectives bypasses these challenges and enables establishment of a highly effective approach to clinical administrative services. It also helps combat burdensome payor “delay and deny” tactics.

The right technology tools, a trusted outsourced service partner, and adherence to best practices let healthcare organizations realize increased efficiency, improved care outcomes, and fewer denied claims while eliminating care and reimbursement delays and reducing associated costs.

Megan DeVoe is Vice President of Coding and CDI Services; and Lina Sanchez, MD, MPH, CCDS, CCS, is Director of Clinical Services with AGS Health.

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How Medical Coding Drives Value-Based Care and Better Patient Outcomes Value-based care is reshaping coding and billing practices, including the role of quality metrics and risk adjustment in reimbursement.

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s healthcare continues its shift toward

value over volume, approximately 60% of healthcare payments in the U.S. are now tied to value and quality. However, while the phrase “quality care” is widely used, it is somewhat misunderstood. Value-based care provides a more precise definition.

The National Academy of Medicine defines value-based care as safe, timely, efficient, equitable, effective, and patient-centered -- STEEEP. While the traditional fee-forservice model rewards providers based on the volume of care, value-based care compensates them based on the quality, equity, and the outcomes they deliver.

Medical coding plays a key role in value-based care models. Assigning the correct codes ensures that patient diagnoses, treatments, and procedures are accurately recorded, which is crucial for assessing the quality of care provided. This article explores how value-based care is reshaping coding and billing practices, including the role of risk adjustment and quality metrics in reimbursement.

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Why the Shift to Value-Based Care?

The experience with the fee-based care models spurred the shift to value-based care. Under fee-for-service, physicians and hospitals are rewarded for volume – they are paid more if they deliver more services, even if they don’t achieve desired results. The value-based care approach changed that dynamic: Providers earn more for delivering care that helps patients get better, while keeping costs down.

The five key goals of value-based care, according to the American Medical Association (AMA) are to: • • • • •

Provide the best patient experience.

Advance health equity.

Improve patients’ health outcomes.

Deliver healthcare services at a reasonable cost.

Support the well-being of the healthcare workforce.

According to the American Hospital Association, about 60% of healthcare payments in the U.S. are tied to value and quality, and the number is continuing to grow.

MORE Role of Quality Metrics and Risk Adjustment in Reimbursement Increased value means lower costs along with improved quality and patient experiences. Value-based care programs foster increased quality (measured through a variety of health metrics) and decreased cost (e.g., keeping patients out of hospitals or emergency departments). Quality metrics are used to track patient outcomes, adherence to clinical guidelines, and patient satisfaction. They help guide reimbursement rates based on performance rather than the volume of services.

The risk adjustment process adjusts payments based on the complexity and risk associated with the patient population. It aims to ensure providers are compensated fairly for the level of care provided, such as treating high-risk patients with complex health needs. By helping to identify high-risk patients, risk adjustment initiatives allow for targeted interventions and preventive measures.

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Medical coding plays a critical role in value-based care by ensuring accurate documentation and reimbursement for healthcare services.

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To demonstrate the delivery of quality care and ensure appropriate payment, providers should ensure their CPT and ICD-10 coding accurately reflects patient complexity.

For measuring quality metrics that inform value-based care initiatives as defined by the AMA, coding should: • Capture patient encounters and treatments, ensuring accurate reporting of care quality.

• Ensure that all patient demographics are accurately documented and represented.

• Capture not only the diagnoses and procedures but also reflect the complexity of a patient’s health condition.

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• •

Define the scope of services provided.

Ensure that the services provided are adequately documented, enabling better workload management.

comes for a specific procedure, the insights provided

by CPT codes can show whether those outcomes have improved compared to previous periods.

Billing for Bundled Services

Tracking a patients’ activities over time is essential for demonstrating the value of care and informing clinical decision-making. It allows healthcare providers to assess treatment effectiveness, identify trends in patient health, and make informed adjustments to care plans. The diagnosis (ICD-10) and procedure (CPT) code sets offer meaningful data insights to support the patient journey and experience.

Medical codes capture the specifics of diagnoses, procedures, and services provided, ensuring that patient care is accurately represented. Clinically specific codes provide substantive data insights for tracking patients’ activities over time.

“Our ability to adequately and accurately describe what we as physicians are doing is as important as ever,” said Ezequiel Silva III, MD, chair of the AMA/Specialty Society Relative Value Scale Update Committee (RUC) in an AMA article.

Role of CPT Codes in Value-Based Care In addition to their use for billing, CPT codes are used for designing new care models and assessing the quality and cost improvements of those models.

CPT codes play a key role in the transition to value-based care.

Standardized Terminology CPT codes are standardized, meaning that they provide a uniform set of codes that describe medical, surgical, and diagnostic services. This standardization ensures that all stakeholders use the same language when discussing procedures. The standardized terminology of CPT codes enables comparison of performance across different providers, facilities, and regions. This comparison can include metrics like procedure frequency, patient outcomes, and adherence to clinical guidelines. Consistent CPT coding allows healthcare providers to track changes in the quality of care over time. For example, if a hospital implements a new protocol to improve patient out-

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Value-based care models often incorporate bundled payments, which encourage providers to deliver comprehensive and efficient care. This approach can cover everything from a comprehensive treatment episode to a specific condition. CPT codes are essential for identifying the services included in a bundle, allowing for clear communication and billing.

Performance Measurement CPT Category II codes are released three times a year. CPT II codes are supplemental codes used to measure performance and help reduce the need for record abstraction and chart review. The CareBased Incentive (CBI) program and the Healthcare Effectiveness Data and Information Set (HEDIS) use CPT Category II codes to evaluate the quality of care provided.

Providers can use CPT Category II codes (0500F-9007F) to report services and/or test results that support performance measures. For example, Patient Management CPT codes (0500F-0584F) allow for tracking ongoing care and management of chronic conditions, which directly impacts quality metrics tied to patient outcomes.

CPT II Categories • • • • • • • • • •

0001F-0015F Composite 0500F-0584F Patient Management 1000F-1505F Patient History 2000F-2060F Physical Examination 3006F-3776F Diagnostic & Screen 4000F-4563F Therapy/Preventive 5005F-5250F F/U & Outcomes 6005F-6150F Patient Safety 7010F-7025F Structural Measures 9001F-9007F Non-Measure Codes

By providing accurate medical data on services such as office, lab, or facility visits, CPT II codes support help HEDIS measures and quality improvement initiatives. For each face-to-face patient encounter,

providers should ensure proper medical record documentation to support the CPT II codes used.

Telehealth Telehealth not only allows for efficient delivery of care but also drives new opportunities for preventive healthcare. Remote monitoring and telehealth visits help patients manage chronic conditions and receive timely interventions, reducing the overall cost of care while improving patient outcomes.

CPT codes related to telemedicine, wearable devices, and health monitoring apps represent the services provided in a digital care setting. The codes can measure telehealth’s impact on quality and value. For example, codes like 99457 (remote physiologic monitoring) ensure that virtual care services are accurately captured, making it easier to track their impact on patient outcomes.

Coordination of Patient Care CPT codes facilitate communication and collaboration among different healthcare providers. The codes allow providers to use standardized terminology to communicate more effectively and share relevant information about patient care and treatment plans. In value-based care, this approach drives holistic and well-coordinated care, leading to better patient outcomes and reducing duplicative services and unnecessary costs.

Using the correct CPT codes within the framework of value-based care promotes better care coordination and improves patient outcomes and cost efficiency.

Now, let’s take a look at diagnosis coding for value-based payment.

ICD-10 Coding for Value-Based Payment In value-based care arrangements, payment is directly tied to the disease burden of the provider’s patient panel. Since sicker patients typically require more resources, providers usually receive more reimbursement when treating these patients.

Accurate ICD-10 coding allows health plans and providers to capture patient complexities, thus ensuring fair compensation under risk-adjusted models.

Conditions that are specific, chronic, and predictive of significantly higher health costs have diagnosis codes weighted for risk adjustment. Using accurate diagnosis codes enable providers to correctly report the patients’ disease burden and ensures appropriate reimbursement.

Example: Correctly coding patients with diabetes complications (e.g., hyperglycemia, diabetic nephropathy, or diabetic neuropathy) will drive better reimbursement and ensure a better understanding of the status of patient panels: • •

For diabetes mellitus without complications, use E10.9 when no other complications of diabetes exist.

If the patient has a complication such as hyperglycemia, use E11.65 - Diabetes mellitus with hyperglycemia.

Diagnosis codes are linked to Hierarchical Condition Category (HCC) codes, which are used by payors to calculate Risk Adjustment Factor (RAF) scores for assessing patient risk.

According to the current HCC model, a patient’s RAF score resets to zero on January 1 each year. Some payors also allow reporting of CPT II codes to enhance ICD-10 coding.

Organizations operating in value-based payment environments need to document and report as many qualifying diagnoses as possible for each patient on an annual basis. This process involves conducting a comprehensive medical history and consistently addressing chronic conditions and health concerns. Using the EHR’s problem list feature is the ideal way to track relevant diagnoses, assign the correct ICD-10 codes to reflect complexity, and closely monitor when the conditions were last addressed.

Aligning Coding Practices With Value-Based Care Objectives Value-based care is a productive approach that aims to hold providers more accountable for improving patient outcomes. To most of the value-based care programs, organizations should identify their patients, sort them by risk, and foster collaboration to manage their chronic conditions. Aligning accurate and detailed coding with the objectives of value-based care allows healthcare organizations to deliver efficient, compliant, and cost-effective care – ultimately improving both patient outcomes and reimbursement.

Amber Darst, CPC, is a Solutions Manager in the Practice and Revenue Cycle Management Department for Managed Outsource Solutions. She brigs several years of healthcare experience to the company, specializing in both Medicaid and Dental billing and insurance verification services. www.managedoutsource.com

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Financing Solutions for a Healthier System: Aligning Patient Financial Health With Healthcare Stability

The financial viability of U.S. health systems is under significant strain due to the increasing volume of uncompensated care. In 2023, U.S. hospitals collectively faced billions of dollars in uncollected revenue, severely constraining their ability to invest in critical infrastructure and advancements in patient care.

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dditionally, many health systems routinely carry carry bad debt exceeding $100 million, with industry experts suggesting a target of 3% of net patient revenue, though most systems exceed this benchmark. This financial vulnerability could threaten the sustainability of healthcare organizations and their ability to provide accessible care to all, stemming from factors such as the growing burden of patient debt, avoidance of preventive care due to financial concerns, and high rates of defection from health systems.

For not-for-profit (NFP) health systems, which are committed to serving their communities regardless of a patient’s ability to pay, managing this financial strain becomes even more complex. These organizations are compelled to balance their mission with the escalating financial obligations of uncollected payments. They

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provide charity care as part of their community benefit, but to remain financially viable and able to reinvest in essential areas such as new technologies, drugs, devices, facility expansions, and rising operational costs, they must secure payment for the majority of services.

However, addressing these financial challenges isn’t solely about improving internal efficiencies. It requires a deeper understanding of the patient’s overall experience, particularly in how they navigate both their clinical journey and the financial responsibilities associated with their care. Engaging patients on both aspects is key to building trust, reducing bad debt, and improving outcomes.

A Holistic Approach to Patient Engagement In addition to care quality, financial wellbeing plays

a crucial role in how patients perceive their care and engage with the healthcare system. This requires a more comprehensive approach to patient engagement – one that balances both clinical and financial aspects of care.

The complete patient experience can be represented by the following equation: Px = PCx + (Pfx * Pfh) Where: • • • • •

Px = Complete Patient Experience PCx = Patient Clinical Experience (focused on “outcomes”) (Pfx * Pfh) = Overall Patient Financial Experience Pfx = Patient Financial Experience (how well they understand their out-of-pocket expenses) Pfh = Patient Financial Health (their ability and assistance to pay these expenses)

In this equation, while clinical outcomes (PCx) remain essential, the financial dimension of care – understanding expenses (Pfx) and the ability to cover them (Pfh) – plays an equally significant role in shaping the overall patient experience (Px). Addressing both sides of this equation is vital for optimizing not just financial performance but also patient trust and satisfaction.

Patient financial health is a growing concern for patients and providers. Without the means to pay out-of-pocket medical expenses, a necessary procedure or therapy, or even ongoing testing to monitor a chronic disease, may be a non-starter. Even with employer-sponsored health insurance, a high deductible plan for a family of four could have a deductible over $16,000.

And this is after paying monthly premiums of $1,000 or more.

The point is that the list of programs available for most patients will still leave a large personal balance to be paid.

Successfully addressing the financial and clinical dimensions

of the patient experience lays the groundwork for the patient to continue on their health journey, for a better episode of care with optimal outcomes, and for a stronger healthcare system.

Delivering this requires targeted strategies across multiple areas of operation.

The 3-Step Approach to Mitigating Financial Challenges There are several contributing factors to these financial challenges, and addressing these requires a multifaceted approach that prioritizes patient financial well-being, optimizing internal revenue cycle operations, and strengthening patient engagement with digital solutions. By focusing on these three areas, healthcare providers can not only alleviate financial pressures but also sustain their capacity to deliver high-quality care to all patients.

1. Implementing Patient Financial Access Programs Implementing, enhancing, and strategically communicating robust patient financial access programs is a critical strategy for reducing bad debt. These programs, which include in-house flexible payment plans, financial counseling, philanthropic and charity care options, drug copay support, access to government programs (Medicaid, ACA plans), and comprehensive patient medical expense financing, play a significant role in mitigating the financial burdens faced by patients. When offered viable, clear financial solutions, patients are less likely to defer care or default on payments. Moreover, financial access initiatives can help improve retention, reducing the likelihood of patients seeking care outside their established health system.

Healthcare financing options can be integrated into these access programs, offering patients another pathway to cover medical expenses. That way, health systems can lower the financial barriers that often lead patients to avoid preventive care. As a result, patients are more likely to attend routine check-ups and follow through on specialist referrals, reducing the long-term cost of care for both patients and the system.

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Incorporating digital tools can greatly enhance patient financial access programs. For instance, offering payment plan enrollment or financial counseling through mobile devices may boost patient participation and promote timely payments. At the time of scheduling, providing an estimated out-of-pocket total or co-pay, along with a simple option to apply for financing, allows patients to cover their balance in a quick and efficient process. This approach can help reduce financial risk for health systems while ensuring that patients can access necessary care without undue financial hardship.

2. Optimizing Revenue Cycle Management Revenue cycle management (RCM) is a key factor in maintaining the financial health of healthcare systems.

By optimizing RCM processes, health systems can capture more revenue while minimizing administrative inefficiencies. Advanced technologies are integral to this, particularly in areas such as real-time insurance verification and patient eligibility checks for government programs, including ACA plans and Medicaid. Errors in insurance discovery – such as missed coverage or incorrectly categorizing patients as self-pay – often occur at the time of service, compounding financial losses.

Implementing technology that accurately identifies insurance coverage at the time of service can significantly reduce payment delays and minimize errors that lead to claim denials. Leveraging these technologies to ensure proper patient enrollment in public health programs also helps decrease uncompensated care. Aiming for Six Sigma-level precision, a methodology that seeks to minimize errors to just 3.4 defects per million opportunities, helps ensure accuracy in insurance discovery. By eliminating mistakes such as missed coverage or incorrect self-pay designations, health systems can prevent issues from cascading through the revenue cycle, protecting both financial outcomes and the patient financial experience.

Health systems may also improve cash flow by collecting a portion of the patient’s financial responsibility at the time of scheduling, provided that payment plans are affordable and accessible. Offering patient financing as an option at the time of scheduling can further reduce the risk of delayed payments. By providing patients with

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flexible financing solutions up front, health systems can help ensure they are financially equipped to cover the costs, thereby reducing the likelihood of debt accumulation later.

3. Strengthening Patient Engagement The evolving expectations of healthcare consumers demand a more patient-centric approach to engagement, with patients increasingly looking for the same digital convenience they experience in other industries. By adopting a consumer-first mindset, health systems can enhance both patient satisfaction and financial performance. Consider how a major online retailer provides reminders of past purchases, suggests related items, and allows customers to complete transactions with just a few clicks – returning items is equally simple and convenient. Health systems can learn from this model by streamlining their processes to offer a similarly seamless, hassle-free experience for patients.

Proactive communication, delivered through digital programs, allows health systems to remind patients of their financial obligations, upcoming appointments, and eligibility for financial assistance. This targeted outreach, coupled with transparent communication about costs, builds trust between patients and providers. Further, when patients understand their financial responsibilities, they may be more likely to adhere to payment plans, improving cash flow and reducing bad debt.

A well-executed patient engagement strategy also enhances a health system’s reputation, positioning it as a provider of accessible, patient-centered care. This can differentiate a health system within a competitive marketplace and contribute to long-term patient retention.

Prioritizing Financial Well-Being for a Sustainable Future To navigate the complex financial landscape, health systems must look beyond traditional methods, embrace emerging technologies, and adopt patient-centered financial strategies that align patient financial wellbeing with operational goals. As highlighted by the patient experience equation proposed above, both clinical outcomes and financial health are critical components of the overall patient experience. By integrating for-

ward-thinking strategies that address these dual aspects, health systems can create a more sustainable financial model while simultaneously improving patient satisfaction and trust, leading to a stronger and more comprehensive care experience.

In addition, investing in innovative solutions to improve insurance discovery processes, offering 0% interest financing to patients, and addressing other critical challenges can provide financial relief while also fostering long-term resilience across the healthcare system. Solutions, such as patient financing, have evolved quickly from other consumer verticals. These solutions are already available and being rapidly deployed by leading organizations, allowing patients to manage their financial responsibilities while reducing the need for heavy collection tactics, which can damage trust and cause patient defection.

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Ultimately, the key to sustained financial health is the willingness to evolve. Health systems that embrace new technologies and refine their RCM processes will be better positioned to overcome or proactively avoid financial challenges and ensure that they continue to effectively serve their communities. By making patient financial health a central part of their strategy, health systems can secure their own financial stability while maintaining a high level of patient care.

Meredith Kirchner is a seasoned healthcare operations leader with over 20 years of experience. She currently serves as the Chief Operating Officer at Curae, where she focuses on improving operational efficiency and client satisfaction through innovative financial solutions for multi-hospital health systems. Meredith has a strong background in healthcare consulting and technology, having held senior roles at Patientco and Ernst & Young. Her experience lies in optimizing organizational workflows and enhancing patient financial access, making her a pivotal figure in driving Curae’s growth and industry reputation.

You focus on you; Curae focuses on financing Curae believe everyone should have options when it comes to achieving optimal health. That’s why Curae is using modern technology to empower people to say yes to the best healthcare for their best selves. Curae works with both providers and their patients to find the best solution. www.curae.com

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Compliance

Healthcare Awareness Spotlight: January Is Cervical Cancer Awareness Month

Happy New Year! The first month of 2025 is packed full of hopes and dreams. January ushers in positivity and the promise of hard work. January sees loved ones striving for optimal health outcomes. It is also the month dedicated to raising awareness about cervical cancer. Ribbons of teal and white are seen prominently worn by those who have been affected by cervical cancer in one way or another – they are the staunch advocates of health literacy, and champions for further research.

W

hat Is Cervical Cancer?

The cervix is what connects the body of the uterus to the vagina. Anyone with a cervix is at risk of developing cervical cancer.

Cervical cancer is a disease that occurs when cells of the lining of the cervix grow out of control. Although cervical cancer starts from glandular or squamous cells with abnormal changes, only some women with these changes of the cervix will develop cancer. For most women, these abnormal cells will be just that – abnormal cells.

But, in some women, these abnormal cells can develop into invasive cancers.

Types of Cervical Cancer There are two main types of cervical cancer: squamous cell carcinoma and adenocarcinoma. Most cervical cancers are squamous cell carcinomas. These cancers develop from cells in the exocervix, or the outer part of the cervix seen during a speculum examination. The other cervical cancers are adenocarcinomas. Adenocarcinomas are cancers that develop from glandular cells. Cervical adenocarcinoma develops from the mucus-producing

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gland cells of the endocervix, or the opening of the cervix that leads to the uterus.

There are less common cervical cancers that have features of both squamous cell carcinomas and adenocarcinomas. These are called adenosquamous carcinomas or mixed carcinomas.

Risk Factors It is important to know the risk factors of developing cervical cancer. Known risk factors include infection by the human papillomavirus (HPV); an early sexual history, with activity starting younger than age 18, and with many sexual partners; chlamydia infection; long-term use of oral contraceptives; three or more full term pregnancies; women younger than age 20 at first full term pregnancy; and smoking.

There are also certain risk factors that you can’t change or improve. These include having a family history of cervical cancer. Another risk factor that cannot be changed includes having received diethylstilbestrol (DES) from 1938-1971. DES was a hormonal drug given to women to prevent miscarriages. Daughters of those women are

also at increased risk of squamous cell cancers.

Research Facts The American Cancer Society® estimates the commonality of cervical cancer in the United States for 2024 will include: • •

About 13,820 new cases of invasive cervical cancer will be diagnosed.

About 4,360 women will die from cervical cancer.

According to statistics from the American Cancer Society®, “Cervical cancer incidence rates decreased by more than half from the mid-1970s to the mid-2000s, largely because of the increased use of screening. However, in women ages 30-44, rates have increased 1.7% each year from 2012 to 2019.”

“In contrast, rates declined 11% each year for women ages 20-24, probably reflecting the first signs of cancer prevention from HPV vaccination.”

Continuing Advocacy It is important to consider the use of HPV vaccinations in children between the ages of 9-12 to prevent cervical cancer. The HPV test and Pap test are also known as screenings that are used to find abnormal conditions or pre-cancers before they can turn into invasive cancers.

Raising awareness for cervical cancer is important all year round.

In January, show your support at local or national organizations, donate funds for research, or attend community walk or run events. You can make a difference in the fight to beat cervical cancer.

Resource: American Cancer Society®: What is Cervical Cancer, Key Statistics, Risk Factors, Prevention Resource: CDC®: Cervical Cancer Basics

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM, is CEO and Principal Strategist at SP Collaborative, LLC.

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Coding

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An Overview of the

2025 CPT

Telemedicine Guidelines Telemedicine has emerged as a routine component of modern healthcare delivery, enabling providers to connect with patients efficiently and effectively. The updated 2025 Current Procedural Terminology (CPT) codes reflect significant strides in formalizing and enhancing telemedicine services. This article explores the nuances of these new codes and guidelines, providing healthcare professionals with the insights needed to navigate the evolving telemedicine landscape.

What Are Telemedicine Services?

The guidelines first describe what is considered a telemedicine service. They are synchronous, real-time, interactive encounters between healthcare providers and patients using either audio-video or audio-only telecommunication technology.

These services are designed to replace in-person visits when deemed medically appropriate. The guidelines also state what they are not; they are not a substitute for routine communication, such as relaying laboratory results. Instead, it serves as a viable alternative for necessary follow-ups, re-assessments, and consultations that align with the standard of in-person care.

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K

ey Components of the 2025 Guidelines

The 2025 CPT guidelines for telemedicine services outline the requirements for accurate reporting and effective use of these services. Telemedicine encounters are categorized based on either the level of Medical Decision Making (MDM) or the total time spent with the patient on the date of the encounter, just as in-person Evaluation and Management (E/M) services. To be reported, these services must occur on a separate calendar date from any other E/M services. Additionally, telemedicine encounters can be initiated by the patient, their caregiver, or the provider, creating flexibility in how care is accessed.

The guidelines emphasize that telemedicine time may be aggregated, or added together, with in-person E/M services on the same day to determine the total service time, provided overlapping time is excluded.

Example: Dr. Smith sees an established patient in the office for a scheduled in-person E/M service. During this visit, Dr. Smith spends 15 minutes discussing the patient’s chronic condition, reviewing treatment options, and adjusting the care plan. Later that day, the patient calls Dr. Smith through a telemedicine platform to clarify instructions about a newly prescribed medication and discuss additional symptoms. Dr. Smith spends another 10 minutes on this telemedicine call.

In this scenario, the time spent during the in-person visit (15 minutes) and the telemedicine encounter (10 minutes) can be added together for a total of 25 minutes when determining the E/M service level for the day. However, any overlapping time—such as the time spent on administrative tasks like scheduling the telemedicine visit—cannot be included in this calculation. This aggregation ensures that the total time accurately reflects the care provided across both interactions while adhering to the CPT guide-

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lines.

Audio-only encounters, covered under codes 98008 through 98015, require a minimum of 10 minutes of synchronous, real-time discussion, excluding asynchronous communication like emails or text messages. These codes ensure that audio-only services remain an effective option when video technology is unavailable or unnecessary. The guidelines also clarify that time spent on administrative tasks, such as scheduling or establishing connections, is not reportable.

The guidelines also address connectivity issues and proper reporting. According to the guidelines, if audio-video communication is interrupted and the remainder of the service relies solely on audio, the provider should report the code reflecting the majority of the interaction time.

Documentation should indicate which form (audio-only or audio-visual) dominated the encounter to support the code chosen.

Example: Dr. Lee conducts a telemedicine visit with an established patient using audio-video communication. The encounter lasts 20 minutes, but during the visit, the video connection is lost after 15 minutes, and the remaining 5 minutes are completed via audio-only. Since the majority of the visit was conducted using audio-video communication, the visit is reported with code 98005, which reflects a 20-minute synchronous E/M service for an established patient. The documentation should clearly indicate the total time spent (20 minutes) and note that the majority of the visit was performed using audio-video technology, with the final portion conducted via audio-only.

New CPT Codes for Telemedicine The new codes (98000–98016) categorize telemedicine encounters into distinct levels based on type, duration, or

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MDM. Audio-video telemedicine codes (98000–98007) cover E/M services provided through interactive audio-video communication. These codes are broken down into new and established patients, with the level of service determined by MDM or total time spent on the date of the encounter. Prolonged services codes may also be reported with 98003, 98007, 98011, 98015, and 98016.

For audio-only telemedicine, codes 98008–98015 are designed for real-time medical discussions that last a minimum of 10 minutes. These services are particularly beneficial when video technology is unavailable, enabling providers to deliver care through verbal communication alone. The codes exclude asynchronous interactions, such as text messages or emails, unless the communication is conducted through devices adapted for patients with hearing impairments.

Code 98016: Virtual Check-In for Established Patients Code 98016 is designated for brief communication technology-based services, such as virtual check-ins, provided to established patients. This service must be patient-initiated and is specifically intended to determine whether a more extensive E/M visit, such as an in-person office visit, is necessary. Unlike other telemedicine services, video technology is not required, making it particularly useful for quick consultations conducted via telephone. The service duration is limited to 5–10 minutes of medical discussion, excluding services lasting less than five minutes. Importantly, this code cannot be reported if the checkin is related to an E/M service provided in the past seven days or leads to another E/M service or procedure within the next 24 hours (or the soonest available appointment). When a virtual check-in leads to a same-day E/M service where time is used to determine the E/M level, the time spent on the virtual check-in can be added to the total E/M time, provided all other conditions are met.

Example: A patient with a history of hypertension contacts their physician, Dr. Jones, via telephone to report symptoms of dizziness and ask whether an office visit is needed. Dr. Jones spends seven minutes discussing the patient’s symptoms, asking about their blood pressure readings, and advising them to adjust their posture when taking medications. Dr. Jones determines that the patient needs a same-day office visit for further evaluation.

Later that afternoon, during the in-office visit, Dr. Jones spends an additional 20 minutes assessing the patient, reviewing medications, and adjusting the treatment plan. Since the virtual check-in (7 minutes) and the in-office visit (20 minutes) occurred on the same day and time is being used to determine

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the E/M level, the two times can be combined for a total of 27 minutes. This allows for appropriate reporting and reflects the comprehensive care provided.

The Future of Telemedicine As telemedicine continues to evolve, the 2025 CPT updates represent a step toward integrating these services more deeply into routine care. By establishing clear guidelines, the American Medical Association (AMA) aims to ensure that telemedicine remains a viable, efficient, and equitable healthcare option.

The 2025 CPT codes for telemedicine services underscore the growing importance of virtual care in today’s health care environment. For providers, understanding these updates is essential for compliance and optimal reimbursement. By leveraging these guidelines, practices can enhance care delivery, improve patient outcomes, and embrace the opportunities telemedicine offers.

Note: This article does not address payor-specific guidelines on the codes’ usage. Please check with your commercial payors to review their guidelines. CMS will not recognize 16 of the 17 new codes discussed in this article. CPT codes 98000-98015 will have a Status of “I” for invalid in the Medicare Physician Fee Schedule for 2025. Medicare will reimburse for the virtual check-in code 98016.

Betty A Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I, is a nationally recognized healthcare consultant and speaker.

She is an expert auditor and loves to help practices stay compliant and profitable. Betty states, “Physicians work hard for their practices and they should be paid properly for what they do.”

Betty brings over thirty years of healthcare experience. She has worked for practices both large and small with the same intensity and attention. She has spent years on the “front lines” for practices handling medical billing, coding, claims, and denials. She has also managed practices and directed healthcare system departments. Her areas of expertise include Evaluation and Management, Primary Care, Dermatology, Plastic Surgery, Cardiology, Cardiothoracic Surgery, General Surgery, GI, E/M and procedural auditing, and ICD-10-CM. chcs.consulting/

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Betty A. Hovey, BSHAM, CCS-P, CDIP, CPC, COC, CPMA, CPCD, CPB, CPC-I Betty A. Hovey is a seasoned healthcare professional with over three decades of experience in the field. She has extensive experience conducting audits for medical practices and payors. She specializes in educating various groups including coding professionals, auditors, doctors, APPs, payors, and others on coding, billing and related topics. Betty is a highly sought-after speaker and has co-authored manuals on ICD-10-CM, ICD-10-PCS, E/M, and various CPT specialty areas.

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HIPAA and Cyber Items to Keep on Your Radar in

2025

Whether it is an electronic health record (EHR) or a personal drugstore app where a consumer downloads and stores their medications, insurance information, and other information, ensuring that adequate technical, administrative, and physical safeguards exist for individually identifiable health information (IIHI) and protected health information (PHI) is a continuing trend for 2025. Additionally, Privacy Rule and consumer privacy, which includes appropriate authorizations by the individual, should also be on the forefront for covered entities, business associates, and consumers alike.

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F

irst, let’s sort out some vernacular. Do you know the difference between MFA, IAM, and PAM?

If you have never heard of any of these terms or need a refresher, here are the definitions: •

•

•

MFA = Multifactor Authentication – This is an essential item to have and to know. In today’s world, more organizations are using a user ID, password, and a third form of identification, such as a verification code that is received via text or email. The purpose is to ensure that users are properly authenticated in this process by enforcing the use of multiple controls to prove that the person attempting to access the application is, in fact, that person.

IAM = Identity and Access Management – This can be thought of as a catch-all term referring to a set of policies, technologies, and processes that manage users’ identities and control access to resources within an entity. Essentially, it identifies users, authenticates them, and manages privileges. An example is assigning role-based access to patient data and having unique IDs and pass codes coupled with MFA and an audit log.

PAM = Privileged Access Management – This is considered a subset of IAM and is usually found in scenarios where an individual or a machine needs access to systems requiring more stringent permissions than a standard user. There should be additional security controls.

The term that most people may be familiar with is MFA. Yet, despite the United Healthcare ransomware attack, which occurred in February 2024 through Change Health, and the subsequent Congressional hearings focusing on MFA, people are slow to adopt this technology. While some reasons are valid (e.g., choosing an MFA application that is secure and reduces the risk of ransomware and other attacks instead of increasing their potential), other reasons are invalid (e.g., making for a perceived more difficult user experience thereby compromising individuals’ data in order to retain their loyalty). The invalid reason is counter-intuitive because if there is a data breach, the risk of individuals not staying with the entity that was hacked decreases. Additionally, as reported in “How Effective Is Multifactor Authentication at Deterring Cyberattacks?” by

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Microsoft, “One study found that MFA prevented 100% of automated attacks, 96% of bulk phishing attacks, and 76% of targeted attacks.” If a consumer’s Amazon account uses MFA, one would think that an app or accessing software containing IIHI or PHI would warrant the same protections.

This brings us to the fact that “The U.S. Department of Health and Human Services (HHS) Office for Civil Rights (OCR) reported that a total of 11 health data breaches have each affected over one million people this year, bringing the total number of people affected by data breaches in 2024 to about 140 million Americans,” as reported in “Change Healthcare Data Breach Officially Affects 100M” by Healthcare Dive. Considering this, it is not surprising that HHS sent a proposed rule to the White House for review, entitled “Proposed Modifications to the HIPAA Security Rule to Strengthen the Cybersecurity of Electronic Protected Health Information.”

In keeping with famed hockey player, Wayne Gretsky’s quote, to look “to where the puck is going,” the remainder of this article highlights two recent HHS-OCR enforcement actions and provides items that covered entities, business associates, and companies offering general health-related applications alike should consider.

Analysis Two recent HHS-OCR enforcement actions – one Privacy Rule and one Security Rule – are instructive of what will likely continue in 2025.

On November 19, 2024, the 51st enforcement action under the HIPAA Right of Access initiative, which requires covered entities to provide patients (or their legal representatives) with their medical records, was announced. Here, the Rio Hondo Community Mental Health Center (California) paid a penalty of $100,000 for failing to provide a patient with the requested medical records after multiple attempts. As reported in “HHS Office for Civil Rights Imposes a $100,000 Penalty Against Mental Health Center for Failure to Provide Timely Access to Patient Records”

by HHS, “Rio Hondo waived its right to a hearing and did not contest the findings of OCR’s Notice of Proposed Determination.”

On October 31, 2024, the 6th ransomware enforcement action under the HIPAA Security Rule was announced.

Plastic Surgery Associates of South Dakota paid $500,000 for several potential violations of the Security Rule following a ransomware attack. As stated in “HHS Office for Civil Rights Settles Ransomware Cybersecurity Investigation for $500,000” by HHS, some of the Security Rule violations, as well as safeguards that were lacking, are outlined below: OCR initiated an investigation following the receipt of a breach report filed by Plastic Surgery Associates of South Dakota in July 2017, which reported that it discovered that nine workstations and two servers were infected with ransomware, affecting the protected health information of 10,229 individuals. The credentials the hacker(s) used to access Plastic Surgery Associates of South Dakota’s network were obtained through a brute force attack (hacking method that uses trial and error to guess passwords, login information, encryption keys, etc.) to their remote desktop protocol. After discovering the breach, Plastic Surgery Associates of South Dakota was unable to restore the affected servers from backup.

OCR’s investigation revealed multiple potential violations of the HIPAA Security Rule, including failures to conduct a compliant risk analysis to determine the potential risks and vulnerabilities to ePHI in its systems; implement security measures sufficient to reduce the risks and vulnerabilities to ePHI to a reasonable and appropriate level; implement procedures to regularly review records of information system activity; and implement policies and procedures to address security incidents.

for what the industry calls “good cybersecurity hygiene.”

These include technological protections like multifactor authentication and strong encryption protections, as well as more behavioral practices like workforce trainings and revoking credentials for employees who leave the workforce.

The Enhanced CPGs are best practices that healthcare entities should employ as their organization’s technology matures. These include network segmentation and conducting attack simulations.

None of these items should come as a shock as most fall under some broader categories, which have been in the Security Rule since its inception.

Conclusion As the new year brings a change in control both in Congress and in the White House, it is important to note that cybersecurity and data privacy, especially in critical infrastructure sectors such as healthcare (including public health), remains bi-partisan in nature, just as it has across the past several administrations.

Organizations should learn from past enforcement actions, familiarize themselves with new acronyms, and look ahead and begin incorporating the anticipated requirements into their annual risk analyses and risk management programs. Training for everyone – from the basement departments to the board room – is also critical for mitigating risk to an organization.

Rachel V. Rose, JD, MBA, Additionally, in light of the HIPAA Security Rule’s proposed rule, there are two new terms (and excitedly the related acronyms) to keep straight: Systemically Important Entities (SIEs); and Cybersecurity Performance Goals (CPGs).

According to RAC Monitor in “CyberSecurity Standards for HIPAA Entities Expected in Upcoming Rule”: Healthcare CPGs are split into two categories: Essential and Enhanced. The Essential category is intended to encompass business practices that are really a baseline

is a disciplined, empathetic, and tenacious attorney advocating for and winning desired legal outcomes for national and international clients. Ms. Rose’s practice includes compliance, transactional, and litigation matters primarily related to healthcare, cybersecurity, securities, the False Claims Act, and Dodd-Frank. She is also affiliated with Baylor College of Medicine where she teaches bioethics. ​ www.rvrose.com

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Rate Increases in Stop Loss or Compliance

Pie in the Sky?

As of recently, some industry colleagues are suggesting that the stop-loss market will produce low double-digit rate increases in 2025. This would suggest that the market is or will be firming up from years of very competitive pricing to the consumers’ benefit, but to the stop-loss insurance industry’s financial disadvantage.

I

n my opinion, there are a number of viables

and measurements that can play into, if not shape, the narrative. That said, I believe that most parties will likely agree that the medical costs are out of hand, and from the insurance industry’s perspective, the stop-loss market has been and continues to be very soft.

Therefore, stop loss is in need of a pricing correction to ensure its long-term viability to consumers.

With the above in mind, when a carrier is expressing a rate increase, it’s important to consider if the increase was the result of any offsets from other product(s) they offer. Multi-line or multi-product carriers leverage this capability to cross sell their products to the same customer. Generally, this type of packaging is provided to larger groups. The advantage is that the carrier can present an aggregate composite pricing for the group.

That is, at renewal, some products will be lower and others higher from the current pricing; however, the bot-

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tom line in totality of the renewal price (aka premium) may be relatively neutral when comparing to the current premium.

Per the National Association of Insurance Commissioners’ (NAIC) Accident and Health (A&H) Policy Experience Report for 2022, the A&H industry premium was valued at approximately $1.2 trillion, with stop loss as a subset at $31.6 billion. This means that stop loss equates to about 2.5% of all A&H premiums. At the A&H group business level, stop loss represents approximately 7% of the premium. In both cases, stop loss represents a small portion of the A&H industry. Another consideration, the top ten stop-loss players control approximately $19.8 billion, which is 63% of the market.

On the other side of the premium are losses and expenses. Often, the industry or carrier will state a loss ratio; however, unless it’s referenced as combined or net, it’s gross, which does not contemplate the expens-

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es incurred (administration, taxes, bureaus, fees, commissions, etc.). These total expenses can range from the low-20 to mid-30 additional percentage points. Incorporating the expense ratio to the gross ratio loss is the true measurement of the industry’s or carrier’s financial performance. Per the NAIC report noted earlier, the A&H industry gross loss ratio of 2022 was 85% with a fiveyear average (2018-2022) is 84%. At the group level, it’s 84.4% and 83.3%, respectively. The historical loss ratio for stop loss has been challenged due to carrier and reinsurer reporting. That said, for 2022, the gross loss ratio for stop loss is projected at 84%.

Therefore, it might not be too much of a stretch to assume that the loss ratio of stop loss will be somewhat similar to the A&H and group level historical loss experience.

Another consideration is the continuous entrance of new players into stop loss. While it’s good to provide consumers with alternatives to price, product, and service, at the same time, any industry should be careful not to compromise the consumers’ outcome but, more importantly, the industry’s financial health. While adding market capacity can be a good thing – as the adage goes: Too much of a good thing can become a bad thing. That said, the reality is that most of these new players are funded by private equity looking for a quick return on their investment with limited consideration to the industry’s loss ratio. Therefore, it’s unfortunate that many new players will “buy” or “burn” their way into the market, thus reducing the needed underwriting discipline to achieve underwriting profit.

Technology has been and will continue to be a vital resource in the insurance industry. Unfortunately, this segment has added additional fuel to the fire. Many players, especially new entrants, are relying on predictive modeling or artificial intelligence underwriting models to drive their operations and manage their expenses. This technology has been largely employed to target small and fully insured groups. The concept can serve well, especially in the fully insured environment when the ground up data offers credible predictability.

The stop-loss industry is looking for options for collecting loss data in lieu of obtaining from the claims payor. Unfortunately, unless the underwriting portfolio is of credible size (law of large numbers), attempting to obtain claimant information to make it into meaningful data for underwriting is similar to one’s inability to hit the broadside of a barn. Whereby inviting claims frequency and a compromised loss ratio. The best data source for underwriting is claims information from the claim’s payor.

It’ll be no surprise that as claim issues arise due to predictive and AI underwriting, the industry will look to employ predictive modeling and AI in claims, without first addressing the initial

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and/or primary issue. That is, the issue may be less claims related and more to do with risk selection and pricing. To that end, I’m a believer that predictive and AI modeling should be used only as tools, and ultimately rely on the underwriters’ judgement based on their experience and skills.

Unlike other products, which are mostly risk transfers, stop loss is an excess product that not only transfers risk but also should be seen as a financial instrument intended to protect an employer from fortuitous large losses. Therefore, it is not intended to transfer the employer’s claims frequency to the stop-loss carrier.

Ideally, the deductible should be affordable for the employer, but high enough to limit the number of claims exceeding the deductible to no more than a handful. Therefore, attempting to model, especially loss rating/experience, any excess insurance product can prove difficult, because by the nature of the product, its severity driven, making it more difficult to predict. Hence, the experienced and skilled underwriter is an invaluable asset in the art of Kentucky windage. These unique and valuable soft market attributes are discussed in a separate article, “The Art and Understanding of Underwriting Practices.”

As you may have gathered from the loss ratio discussion above that the insurance industry is often challenged in making an underwriting profit – whereby the combined or net loss ratio is less than 100%. Therefore, the insurance industry relies on their investment income until the stock market is not in a position to offset the combined loss ratio. Consider the Dow, which has grown 24% in the last year and nearly 55% during the past five years. S&P was nearly 31% and 89%, respectively.

In my opinion, meaningful rate increases will likely be achievable when one of two things occurs: tightening of the reinsurance market or the stock market starts to perform poorly. Until then, on a monoline basis, I anticipate the best case for stop loss is mid-single digit rate increases for the foreseeable future. While the industry will agree that a significant rate increase is needed to achieve an underwriting profit, I believe the reality is that the market will remain soft for all the reasons noted.

Joe Dore is president of USBenefits Insurance Services. Joe is an Underwriting and Marketing executive with over thirty years of managerial experience in the insurance industry. www.usbstoploss.com

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Compliance

Medicare Advantage Plans: Coding Challenges and Best Practices Understand the existing coding challenges for Medicare Advantage plans and some best practices for ensuring better compliance.

I

n the ever-evolving medical landscape,

Medicare Advantage (MA) plans are becoming increasingly popular. MA plans, offered by private insurers that are approved by Medicare, provide an alternative to conventional Medicare by clustering Part A, B, and often Part D, as well. This means beneficiaries get comprehensive coverage that goes beyond what traditional Medicare offers.

However, for healthcare providers, MA plans present some unique challenges, especially in the domain of medical coding and relevant documentation.

Circumventing these challenges holds the key in ensuring precise reimbursements, compliance, and ultimately, enhanced patient care. This article explores Medicare Advantage plans, the associated coding challenges, and some best practices healthcare providers can adopt to

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overcome them.

Medicare Advantage – Plans and Benefits Medicare Advantage, commonly known as Part C, includes the benefits of Parts A and B, and often includes additional coverage. MA plans include private fee-for-service plans, Health Maintenance Organizations (HMOs), Preferred Provider Organizations (PPOs), and Special Needs Plans (SNPs). Each plan comes with its own coverage rules and healthcare network, allowing beneficiaries to choose from a wide range of options.

Medicare Advantage plans often provide benefits that aren’t covered in standard Medicare. These can include dental care, vision exams, wellness programs, and even home-delivered meals and transportation services for those who need it. For chronically ill patients, most

plans provide resources for care coordination to manage the patient’s overall condition in a better way. The integration of all these benefits makes MA plans an excellent choice for the beneficiaries who are seeking something better than traditional Medicare.

Medicare Advantage Payment Model and the Significance of Risk Scores The key differentiator between Medicare Advantage and Medicare is the payment model. MA plans are paid a capitated amount to cover care for the patient, which are adjusted based on the patient’s risk score. This payment model is different from Medicare’s Fee-for-Service (FFS) model, where the providers are compensated for the service they provide.

The decisive factor in determining the amount paid to the MA plans is the risk adjustment factor. The payment model changes based on the health status and demographic characteristics of the beneficiaries. The risk score decides the estimated medical cost of a beneficiary based on parameters such as age, gender, disability status, and the presence of certain chronic conditions.

the insurance plan.

This focus on health status in Medicare Advantage coding has led to the implementation of the coding intensity adjustment. To account for the greater differences in coding intensity between MA plans and FFS Medicare, CMS adjusts payments to MA plans to account for differences in coding intensity between MA plans and FFS Medicare. This adjustment is intended to prevent overpayment to MA plans that code more aggressively than FFS. One of the challenges with the coding intensity adjustment is ensuring transparency in the reflection of differences in the health status of beneficiaries. Adjustments should take into consideration that MA plans are often held by more vulnerable populations that have more complex health needs. Meanwhile, concerns about upcoding – where providers purposefully code conditions that are more severe than what they actually are to increase payments – have led to a tighter scrutiny of MA’s coding plans.

Implications of Upcoding

Accurate coding is essential to ensure appropriate risk scores.

The coding process involves precisely categorizing the health conditions of patients through the ICD codes. It is vital to accurately capture the beneficiary’s health conditions through the most specific codes. If not, it can lead to underpayment to the plan. Conversely, if coding is exaggerated, it can result in overpayment or upcoding, which can lead to serious legal repercussions.

Upcoding happens when providers assign a code that reflects a more serious or complex condition than what the patient actually experiences, for the sole purpose of increasing payments from MA plans. While a few of the incidents may be unintentional due to the intricacies of the ever-evolving coding system, deliberate upcoding can attract significant financial penalties. While CMS scrutinizes to prevent and detect upcoding, RADV audits identify scenarios that do not accurately capture the patient’s health status.

Medicare Advantage vs Fee-for-Service Coding Practices

Coding Challenges With Medicare Advantage

The coding practices under Medicare Advantage are entirely different from that of traditional Fee-for-Service (FFS) Medicare.

Under FFS Medicare, providers get paid for the specific services rendered to patients. Therefore, coding under FFS is primarily centered on documenting the specific services rendered during an encounter with a patient. However, in Medicare Advantage, coding is centered on capturing a patient’s overall health status to determine the risk score that influences payments made to

Precise coding in MA has been a force to reckon with – since its inception in the healthcare system. The main coding challenges Medicare Advantage plans face include CMS Risk Adjustment Data Validation (RADV) audits, social determinants of health (SDOH), and telehealth and remote care services.

Risk Adjustment Factor (RAF) Scoring

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The foremost challenge plaguing the healthcare sector in terms of MA plans is accurately capturing the patient’s clinical conditions and demographics, so that the CMS can determine how much to pay to the patient’s particular health plan each year. CMS does this by using Hierarchical Condition Categories (CMS-HCCs) to calculate risk scores that directly affect the reimbursement rate.

Ensuring providers accurately capture and code chronic conditions is a challenge. Lack of clarity in the documentation or upcoding/undercoding can lead to overpayments or underpayments and attract penalties.

CMS Risk Adjustment Data Validation (RADV) Audits CMS performs RADV audits on Medicare Advantage plans to ensure that the diagnosis codes submitted are accurate and adequately documented. The purpose of the RADV audits is to recover overpayments associated with erroneous coding, and ensure all overpayments identified during these audits are to be repaid by MA plans. Preparing for and responding to RADV audits is labor-intensive and time-consuming for plans, as they must be required to provide adequate documentation for every diagnosis code submitted.

The biggest challenge associated with RADV audits is the retrospective application process involved. A diagnosis that was appropriate during the time of coding could be brought into question later, requiring the plan to go back and redo the clinical situation with adequate documentation. If the said documentation is found incomplete or missing, the plan could be penalized.

Coding for Telehealth and Remote Care The COVID-19 pandemic encouraged telehealth as a key area in healthcare provision. Telehealth services have been rapidly covered by MA plans, but coding of telehealth and remote care presents its own set of complexities. Often, providers are unfamiliar with the specific and relevant codes to assign for telehealth services. Another aspect is regarding the kind of documentation done for telehealth visits, which is different from other in-person visits.

As CMS refines the rules regarding telehealth reimbursement, providers offering MA plans need to stay up to date to code and bill their services accurately. This can be especially challenging as telehealth emerges as a permanent fixture within the U.S. healthcare system.

Best Practices in Managing MA Plan Challenges Providers can opt for the following best practices to overcome the challenges and ensure compliance: 1.

2.

SDOH Coding As healthcare systems incorporate the impact of social determinants of health on patient outcomes, the necessity of accurate coding for SDOH has become critical. SDOH includes conditions such as housing instability, food insecurity, lack of transportation, and many other socioeconomic conditions that affect a patient’s health. Medicare Advantage plans involving vulnerable populations are usually the ones in the forefront of addressing these issues.

3.

4.

Due to its infancy, many providers are not sure how to document and code these risk factors. The ICD-10 has developed a set of codes for SDOH, but providers may not always gather the necessary data to assign these codes.

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Addressing the Social Determinants of Health (SDOH): Accurately capturing and coding of SDOH should take place in collaboration with providers.

This may entail upgrading the data collection process and educating the providers on the significance of the documentation of SDOH. Comprehensive Documentation Procedure: A standardized documentation guideline should be implemented by the providers, ensuring all significant data relevant to the patient’s conditions are captured during his/her visit. The documentation must be clear and complete, with every diagnosis marked and adequately justified.

Staff Training: Imparting regular, updated training to coders and providers alike is crucial to reduce errors in the process. Providers need to be trained in documenting patient conditions accurately, especially in high-risk areas, prescribed under the HCC (Hierarchical Condition Category). On the other hand, coders should be proficient in rules on both CMS and MA plans which would ensure the transparency of clinical documentation.

Regular Chart Audits: Auditing patient charts on a time-to-time basis can mitigate errors related to diagnosis and procedure coding. Audits can help identify documentation/diagnosis mistakes and coding errors. The subsequent feedback from these

5.

6.

audits can help coders and providers understand their mistakes and reduce risks of any consequences in the future.

Adoption of Advanced Tools and Software: Investing in Electronic Health Record (EHR) systems with Artificial Intelligence (AI) can not only automate repetitive tasks and accelerate the coding process but can also help detect errors in documentation and suggest feedback on how to improve accuracy.

Patient Health Assessments: Patient Health Assessments (PHAs) usually serve as an information gathering tool that MA plans often rely on for beneficiaries’ health status.

Involving patients in PHAs can help providers capture a broader view of the patient’s health conditions, thus ensuring proper coding and more effective management of patient care.

Conclusion According to the article, “Quality, Health, and Spending in Medicare Advantage and Traditional Medicare” published in The American Journal of Managed Care (AJMC), 52% of the analyses favored Medicare Advantage as opposed to the 13% favoring traditional Medicare. The systemic review also revealed that the MA beneficiaries experienced better quality of care, better health outcomes, and lower costs compared with traditional Medicare.

Medicare Advantage offers great welfare for the patients but at the same time presents a unique set of challenges for providers and coders that can negatively impact coding accuracy and compliance. By focusing on producing comprehensive documentation, regular staff training and auditing, and staying up to date with the current guidelines, healthcare providers can reduce claim denials, thereby optimizing reimbursements and maintaining compliance. By adopting these best practices, providers can bypass roadblocks related to the ever-evolving landscape of MA plans, ensuring steady financial outcomes and enhanced patient care.

Loralee Kapp is a Solutions Manager at Managed Outsource Solutions, holding a degree in Health Information Management and Technologies.

With over five years of experience in medical coding and health information management, she has been a valued member of the MOS team since 2021.

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Compliance

Monthly Spotlight on Fraud, Waste, and Abuse The following cases highlight fraud, waste, and abuse (FWA) and serve as a reminder to uphold high ethical standards when providing patient care and services.

D

rug Maker Teva Pharmaceuticals

Agrees to Pay $450M in False Claims Act Settlement to Resolve Kickback Allegations Relating to Copayments and Price Fixing Teva Pharmaceuticals USA Inc. (Teva USA) and Teva Neuroscience Inc. (collectively, “Teva”) have agreed to pay $450 million to resolve two matters that allege Teva violated the Anti-Kickback Statute (AKS) and the False Claims Act (FCA). Teva, headquartered in Parsippany, New Jersey, is the largest generic drug manufacturer in the United States. The settlement amount was based on Teva’s ability to pay.

“Kickbacks designed to induce referrals or purchases of healthcare goods or services distort physician and patient decision-making, thwart competition, and bypass

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controls put in place to protect federal healthcare programs,” said the Principal Deputy Assistant Attorney General on the case.

The settlement encompasses two alleged kickback schemes. First, Teva has agreed to resolve allegations in a complaint the United States filed in the District of Massachusetts in August 2020 that Teva violated and conspired to violate the AKS and FCA by paying Medicare patients’ cost sharing obligations (copays) for the multiple sclerosis drug Copaxone from 2006 through 2017, while steadily raising Copaxone’s price. In particular, the United States alleged that Teva coordinated and conspired with multiple third parties, including a specialty pharmacy and two allegedly independent copay assistance foundations, to ensure that purported donations to the foundations were used specifically to cover the copays of Medicare Copaxone patients, which

Teva knew was prohibited by the AKS, and that Teva thereby caused the submission of false claims to Medicare.

Second, Teva USA has agreed to resolve separate allegations that it conspired with other generic drug manufacturers to fix prices for pravastatin, a drug widely used to treat high cholesterol and triglyceride levels, as well as two other generic drugs, clotrimazole and tobramycin. Teva USA previously entered into a deferred prosecution agreement with the Justice Department’s Antitrust Division to resolve related criminal charges. Teva USA paid a criminal penalty of $225 million and admitted to conspiring with three other generic drug companies to fix prices on certain generic drugs. Under the announced civil settlement, Teva agreed to resolve allegations that the benefits it received under its price fixing scheme constituted illegal kickbacks.

Teva will pay collectively $450 million to resolve the two kickback schemes. This payment is in addition to the criminal penalty paid by Teva USA under its deferred prosecution agreement.

Since 2017, the United States has collected over $1 billion, in addition to this recent settlement, from pharmaceutical companies that allegedly used third-party foundations as conduits to unlawfully pay patient copays. The department has also reached settlements with four foundations and a specialty pharmacy pertaining to those allegations. This recent resolution with Teva is the largest of these settlements to date. The settlement of Teva’s price fixing conduct is the seventh pertaining to allegations of price fixing involving generic drugs, with total recoveries exceeding $500 million.

Source: Drug Maker Teva Pharmaceuticals Agrees to Pay $450M in False Claims Act Settlement to Resolve Kickback Allegations Relating to Copayments and Price Fixing (2024, October 10). www. justice.gov Physician Charged in Scheme to Illegally Sell Cancer Drugs Late October saw a physician charged in an indictment for his role in a multi-million-dollar scheme to illegally sell and divert expensive prescription cancer drugs. Charged in the indictment is a doctor from West Bloomfield, Michigan.

The charges against him include one count of conspiracy to illegally sell or trade prescription drugs, and 10 counts of illegally selling or trading prescription drugs.

According to the indictment, by early 2019, and continuing through August 2023, this licensed physician worked with others to buy and sell expensive cancer drugs for profit and with the intent to defraud and mislead. The other individuals he worked with identified customers interested in buying prescription cancer drugs, and they communicated with him about what cancer drugs were requested. He used his access to certain cancer drugs through his medical practice, Somerset Hematology and Oncology, P.C., to order and purchase the cancer drugs from his supplier. He then sold the cancer drugs to and through the other individuals’ company to the eventual customer. During this scheme, he acquired and sold more than $17 million in prescription cancer drugs, and personally profited more than $2.5 million.

“The safety and integrity of our country’s prescription drug supply lines – particularly for cancer drugs – is an important part of our healthcare system,” stated the U.S. Attorney on the case. “As alleged, the doctor used his role as a physician to violate that integrity and divert prescription cancer drugs away from treating patients. My office is committed to prosecuting medical professionals who seek to profit, rather than protect, our healthcare system.”

A Special Agent in Charge of the FBI in Michigan stated, “Having the authority to prescribe medication is a privilege that comes with a profound responsibility. Physicians must safeguard against drug diversion.” The agent continued, “The doctor’s alleged participation in this scheme not only allowed him to profit unlawfully from the sale of cancer drugs but it also posed a serious threat by potentially placing these medications into the wrong hands. This breach of trust is inexcusable, especially considering the critical nature of the drugs involved. The FBI is unwavering in its commitment to hold medical professionals accountable for exploiting their positions for personal gain and endangering community safety.”

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An indictment is only a charge and is not evidence of guilt.

Source: Physician Charged in Scheme to Illegally Sell Cancer Drugs (2024, October 25). www.justice.gov Medical Billing Company Owner Pleads Guilty to Healthcare Fraud A New York medical billing company owner pled guilty to healthcare fraud in late October.

He admitted that from approximately April 2020 through April 2023, he acted as the office manager and healthcare claims biller for two physicians’ practices in Plattsburgh through a company that he formed called SJ Healthcare Management Services, LLC (SJHMS). SJHMS charged a fixed monthly fee under which he performed various management, administrative, and billing services for the practices. He admitted that he submitted false and fraudulent claims to public and private insurers on behalf of those practices for services that, in some instances, were never provided and, in other instances, were provided at lower reimbursement rates than the amounts billed. For example, he admitted that he submitted claims to insurers for medical procedures that were purportedly performed by a provider on him but which, in fact, never occurred.

He is scheduled for sentencing on February 28, 2025. He faces up to 20 years in prison and a term of post-imprisonment supervised release of up to three years. A defendant’s sentence is imposed by a judge based on the statute the defendant violated, the U.S. Sentencing Guidelines, and other factors.

of electro-acupuncture devices on patients. The placement of these devices was improperly billed using Healthcare Common Procedure Coding System (HCPCS) code L8679, which resulted in Apple receiving payments from Medicare to which it was not entitled.

HCPCS code L8679 is a billing code for “implantable neurostimulator, pulse generator” devices that are surgically implanted into the central nervous system or targeted peripheral nerves through procedures that are typically performed by a surgeon in an operating room. However, the United States contends that Apple falsely billed Medicare using HCPCS code L8679 for electro-acupuncture devices it knew were not surgically implanted into their patients and for procedures that did not involve anesthesia or take place in an operating room. The underlying services for which Apple submitted the HCPCS code L8679 claims involved the application of a device used for electro-acupuncture. The electro-acupuncture devices were applied by inserting needles into patients’ ears and by taping the devices behind their ears with an adhesive. Medicare does not reimburse for electro-acupuncture devices billed as neurostimulators and did not reimburse for acupuncture during the period of the covered conduct.

This investigation resulted from a coordinated effort between the U.S. Attorney’s Office for the Eastern District of Tennessee, the Office of Inspector General of the U.S. Department of Health and Human Services, and the Southeastern Unified Program Integrity Contractor.

The claims settled by this agreement are allegations only, and there has been no determination of liability.

Source: Medical Billing Company Owner Pleads Guilty to Health Care Fraud (2024, October 29). www.justice.gov

Source: Chattanooga Provider Settles Allegations of Improper Billing for Electro-Acupuncture Devices (2024, October 18). www.justice.gov

Chattanooga Provider Settles Allegations of Improper Billing for Electro-Acupuncture Devices

Sonal Patel, BA, CPMA, CPC, CMC, ICDCM,

Apple Corporate Wellness, Inc., now known as Bryn Medical Center and Basket Medical PLLC (collectively, “Apple”), agreed to pay $1,148,598 to resolve allegations that it knowingly and improperly billed Medicare for electro-acupuncture using auricular stimulation devices in violation of the False Claims Act. Apple was an outpatient clinic located in Chattanooga, Tennessee that offered medical and chiropractic services for the treatment of pain. According to the settlement agreement, the United States contends that for dates of service between June 28, 2016, and June 19, 2017, Apple presented, or caused to be presented, to Medicare false claims for payment for the placement

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is CEO and Principal Strategist at SP Collaborative, LLC. Sonal has over 13 years of experience understanding the art of business medicine. She is a nationally recognized thought-leader, speaker, author, creator, and consultant. As the CEO & Principal Strategist of SP Collaborative, LLC, she serves as a partner to healthcare organizations, medical practices, physicians, healthcare providers, vendors, consultants, medical coders, auditors, and compliance professionals in working together to elevate coding compliance education for the business of medicine. spcollaborative.net/

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Compliance

The Three Essentials for Success It is a pivotal time in the medical billing industry as reimbursement pressure still abounds, many clients and potential clients are merging or becoming employees of larger entities, and management fee price competition is more rampant than ever in the history of our industry.

E

veryone is faced with the choice

to either continue to go with the flow and hope you can, as the song says, “Let’s hang on to what we’ve got” (The Four Seasons), or become proactive and grow and prosper. However, measures must be taken to ensure you can become a better version of who you are today.

Continued success in the medical billing industry will require a three-pronged approach if you want to continue to build a vibrant profitable company.

The three areas you should concentrate on are: • • •

Building bench strength Embracing technology Networking, selling, and marketing

In many companies, the owner is responsible for every aspect of their company –staff development, technological choices, and growth of the business – but when one person is responsible for all three areas, it’s impossible to grow and improve.

So, let’s take a closer look at the three areas mentioned above.

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Building Bench Strength It is important that you surround yourself with people who don’t just know what to do, they know “the why.” It’s imperative that you or someone on your team “makes” the time to teach and mentor every employee in your organization as to why something is important. When everyone understands why something needs to happen versus just how to perform a duty, then they may be able to be a contributor to developing or modifying how something should be done.

I’m a firm believer in cross training for every team member. Each person should spend time doing every job unless it’s one that requires special knowledge like coding. However, coders should spend time learning every other position. When everyone is exposed to how all the pieces fit together and how one department affects another, it leads to people understanding how important it is to do things right the first time to eliminate unnecessary rework.

Embracing Technology The second area that will help you improve service to your clients and reduce your operating costs is the adoption of the latest technologic tools such as artificial intelligence software – which is evolving monthly – and

Robotic Process Automation (RPA) bots. Plus, you need patient and client portals.

It will be hard to be price competitive in today’s marketplace if you are stuck in a “manual” versus a “tech savvy” environment.

Networking, Selling, and Marketing Finally, you must become a persistent networker. The days of growing your business by simply waiting for referrals are almost nonexistent. An advantage of having a well-trained staff is that you can dedicate more time to sales and marketing. To be considered a valuable billing company, you should be growing your top-line revenue at a net rate of 10 to 20 percent per year. Without any sales effort, you will probably experience a net decline in revenue of 10 to 20 percent per year and eventually reach a point where you cannot even cover your fixed costs.

The good news is that anyone can learn how to become a successful salesperson.

You can find thousands of “how to” books written specifically to help a person without any selling skills turn into a selling machine. The key is not just buying books but actually reading the books and implementing their techniques and suggestions.

When you discover a book that you find informative and helpful, I’d recommend that you purchase the audio version too so you can listen to it over and over. I’ve owned an audio program for many years – “21 Great Ways to Become a Sales Superstar” by Brian Tracy – and listened to it dozens and dozens of times and still learn something new each time I listen to it.

Conclusion It all boils down to choice. You can keep trudging along, hoping that good things will happen on their own, thinking that what worked in the past will work in the future; or you can be proactive and adopt the philosophy that you want to improve yourself and your company each and every day. Regardless of your choice, your future lies in your hands.

Dave Jakielo is an International Speaker, Consultant, Executive Coach, and Author, and is President of Seminars & Consulting. Dave has been helping companies grow and improve their profitability for over four decades. Sign up for his FREE weekly Success Tips at www.Davespeaks.com. Dave can be reached via email Dave@ Davespeaks.com; phone 412-921-0976.

Davespeaks.com

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Us E C / ars Webin Billing & Coding CEUs: The FAST, EASY, and AFFORDABLE way!

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Myson Joseph with MLJ Consultancy LLC delivers practical HIPAA compliance advice, walking you through the HIPAA compliance journey to help you better understand how to achieve and maintain HIPAA compliance in your healthcare organization.

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