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Position may influence denials on patient relationship modifiers
03/24/2025
by: Julia Kyles, CPC
Look at your claims with patient relationship modifiers X1-X5 and move the modifier to the second position if you’re seeing high denials.
What’s behind Medicare Advantage growth drop? Benefit cuts, prior auth cited.
03/17/2025
by: Roy Edroso
New numbers suggest that the growth of Medicare Advantage enrollment, which has been faster than traditional Medicare’s for years, has begun to slow. The program faces headwinds, some self-generated, as beneficiaries see potential reductions to their benefits and their providers decoupling from plans.
OCR alert addresses human vulnerabilities in social engineering attacks
03/17/2025
by: Dom Nicastro
The October 2024 Cybersecurity Newsletter from the Office for Civil Rights (OCR) focuses on social engineering — a significant and growing cyberthreat aimed at exploiting individuals to gain unauthorized access to sensitive information.
You need a scorecard to track telehealth coverage in 2025
03/17/2025
by: Julia Kyles, CPC
You know that CMS will not reimburse the new CPT telehealth codes (PBN 1/23/24). However, some commercial plans are picking up the new codes (98000-98015).
Doing the splits: MDM offers more flexibility for split/shared visits
03/17/2025
by: Julia Kyles, CPC
The answers to a reader’s questions about split/shared visits demonstrate that medical decision-making (MDM) can boost your care team’s effectiveness.
Roster billing for hepatitis B — July 2025 release
03/17/2025
by: DecisionHealth staff
On Feb. 21, CMS published Medicare Claims Processing Transmittal 13091 to communicate the roster billing process for submitting Part B claims for hepatitis B vaccines and their administration. CMS recently expanded coverage of hepatitis B vaccinations to include individuals who have not previously received a completed vaccination series and individuals whose previous vaccination history is unknown.
Denial trends favorable on 59-appended procedural services
03/17/2025
by: Richard Scott
Practices upped their use of modifier 59 (Distinct procedural service) in recent years, adding nearly 1 million 59-appended claims to the most frequently reported same-day procedural codes.
In trend, court limits drug rebate AKS charges to easier ‘but-for’ standard
03/10/2025
by: Roy Edroso
A recent ruling on the False Claims Act (FCA) implications of the anti-kickback statute (AKS) appears to be part of a trend that may protect you from escalated penalties if you’re charged with AKS violations.
Compounded GLP-1s set to exit market, ending your ability to prescribe
03/10/2025
by: Roy Edroso
The brisk online market in compounded versions of GLP-1s — less expensive than the first-line, on-patent versions such as Ozempic — are about to lose their FDA shortage authorization. Know the deadlines, which would end your ability to prescribe them.
Pass along knowledge on the new transfer of care rule
03/10/2025
by: Julia Kyles, CPC
Take time to brush up on transfer of care modifiers in the wake of Medicare’s new rule for procedures with a 90-day global period. But be aware that there’s some good news surrounding this update: The final version of the new rule is much simpler than the proposed rule. 
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